Biopsychosocial Psychiatry

To the Editor: Drs. Gabbard and Kaye wrote an excellent article on the biopsychosocial psychiatrist, but what happened to the social slant? The only remotely social aspect to their article deals with the important question of whether “two treatments [are] better than one” (p. 1957) and then only if one regards the patient and the two therapists as a small society. One hopes—indeed, is sure—that they know about the value of couples and family treatment, not to mention issues of ethnicity, race, community, etc. It is known, for instance, that when there is both marital discord and depression that couples therapy is more effective than treating the depressed person alone (1) and that in work in schizophrenia, collaborating with the family is vital for success (2).

One is left with the question why—and it is a common practice—the social part of the biopsychosocial model is omitted, not only by two such wise psychiatrists, but almost always. It is perhaps that they, like most psychiatrists, are interested in the individual patient and not in social issues. Thus, it is not surprising that in the excellent residency training program in which I teach at Cambridge Hospital, a resident spends 60 hours (less than 1% of his or her time) during all 4 years learning about and working with couples and families, the social, and 99% of his or her time with the “biopsycho,” a practice doubtless mandated by the boards.

Fortuitously, in the article that followed the one by Drs. Gabbard and Kay, the importance of the spouse is illustrated in a brief clinical vignette titled “Husband and Wives” (3).