The Rise and Fall of the Biopsychosocial Model: Reconciling Art and Science in Psychiatry

The Rise and Fall of the Biopsychosocial Model: Reconciling Art and Science in Psychiatry

by S. Nassir Ghaemi, MD, MPH. The Johns Hopkins University Press, Baltimore, MD, 2010, 253 pages, $50.00 (hardcover).

The title of this impassioned and thoughtful book contains a thesis and a goal. Ghaemi has produced both a penetrating analysis of the ascent of the biopsychosocial model as a psychiatric theory-of-everything and a weapon designed to bring about its decline. Others have attempted to predict or precipitate a biopsychosocial backlash. Paul McHugh and Phillip Slavney receive special attention from Ghaemi in this regard, and it is perhaps telling that the Johns Hopkins University, where their ideas originated and flourished, published this volume. However, Ghaemi’s may be the most specific, studied, and sustained assault on the biopsychosocial model to date.

Many will wonder why such an assault is warranted. After all, what could be wrong with the biopsychosocial model’s mandate of multidimensional attention to "the whole patient"? Yet it is precisely this diffuse, pat imperative that Ghaemi finds not merely impractical but demonstrably harmful to psychiatry and its patients. The first several chapters of Rise and Fall chronicle the evolution of eclecticism in 20th-century psychiatry in a manner that simultaneously makes the argument for challenging its seemingly unassailable conceptual inclusiveness. Ghaemi stakes important claims that cannot be dismissed out of hand. Among these is a convincing argument that the biopsychosocial model ultimately emerged from George Engel’s desire to make an increasingly biological psychiatric world safe for psychoanalytic influence. This motive, along with other factors, allowed one form of dogma to give way to another. As dogma, the biopsychosocial model is shown to benefit from a sort of faith-based initiative blind to its faults. Ghaemi locates those faults in the eclecticism of the biopsychosocial model. He argues that, far from the open-minded, thinking-person’s intellectual asset, eclecticism with the biopsychosocial model as its official face has left psychiatry bereft of rigorous conceptual backing and thus prone to stunted science and undisciplined clinical patient care.

As a corrective to the biopsychosocial model’s shortcomings, Ghaemi offers his concept of "method-based psychiatry," a rationale by which an approach can be selected and defended by a clinician or investigator focusing on a given form and context of psychopathology. This rationale blends Osler’s "medical humanism" (which Ghaemi sees as rejected by the biopsychosocial model’s insistence on approaching human beings "scientifically") with artistic and philosophical approaches to understanding mental phenomena. Some rather dense philosophical review undergirds Ghaemi’s alternative to the biopsychosocial model. While an iconoclastic proposal demands thorough justification, I found myself sufficiently bogged down in these sections that their conclusions ended up seeming almost tautological (ie, "this is the correct method because my methodology has determined that it is"). Ghaemi is obviously both enthusiastic and well-informed on his subject, but a bit more distillation might have led to some explanatory addition by subtraction. In contrast, Ghaemi provides an elegant and nuanced portrayal of William Osler’s medical wisdom. This section, along with earlier ones on Adolf Meyer, Roy Grinker, and George Engel, offers a mixture of scholarly research and informed speculation of great value to those teaching or otherwise interested in the history and conceptual underpinnings of psychiatry.

When I used the word weapon in reference to Rise and Fall earlier in this review, I was not kidding. While Ghaemi’s research and reasoning for the most part stand on their own merits, he pulls no punches in presenting both forcefully. Intentionally or not, the book is both intellectually and emotionally provocative. This tone engages the reader even when the content gets occasionally dry or repeats itself in order to drive a point home. Further, it is clear that Ghaemi cares deeply about the state of psychiatry and the plight of the mentally ill and is outraged by what he sees as a lack of rigor in the derivation and utilization of "biopsychosocial" as a model and as a banner. By showing mettle, he gives credibility to his plea for the field to wake up and think.

Ironically, though, the impassioned nature of the book might impede its persuasiveness. I, for one, am sympathetic to Ghaemi’s criticisms of the biopsychosocial model but worry that by talking too tough about a strongly held, and at least superficially good, idea, he might drive away those whose minds he is trying to change. Rise and Fall raises questions that psychiatry cannot afford to have posed only in a sermon to the choir.

While it is customary to end a medical book review with some kind of statement that the volume in question "belongs on the shelf of every physician," I will not do so here. This book belongs on the shelf of only those willing to question some of their basic assumptions about contemporary psychiatry. The reader needs to be willing to take a punch—and to give one, since both sorts of willingness are essential to the kind of thought that this book and our times demand.

Nicholas Kontos, MD

nkontos@partners.org

Author affiliations: Massachusetts General Hospital, Harvard Medical School, Boston.

Potential conflicts of interest: None reported.

doi:10.4088/JCP.11bk07158

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