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

This book is about a very important topic—the overarching conceptual framework of our field of psychiatry. Since the decline of the psychoanalytic hegemony in American psychiatry, and the incomplete dominance of our field by biological reductionism, Ghaemi argues that the biopsychosocial model has been the closest we have had to a framework within which to think about our patients and organize our research. In this book, Ghaemi argues—with much force—that the biopsychosocial emperor is, if not buck naked, embarrassingly poorly clothed. He takes us through the history of the theory, giving a place of honor to Roy Grinker, in addition to describing the better known seminal role of George Engel. Ghaemi argues that the biopsychosocial model is superficial and tells us little of real value. It says nothing about the critical question of how bio-, psycho-, and social influences actually interact to produce illness. By saying "let a thousand flowers bloom," it really says little. The biopsychosocial model does not support critical thinking and can even be anti-intellectual by insisting that every perspective must always be considered. This approach, he writes, "gives mental health professionals permission to do everything but no specific guidance to do anything" (p. 82) and can produce, in his nice turn of phrase, "paralysis by complexity." As Eric Kandel has well illustrated, sometimes it is important to focus on just one aspect of things and at least for many years ignore other factors. In his afterword, Ghaemi summarizes his position: "the BPS model has never been a scientific model or even a philosophically coherent model. It was a slogan…" While this may strike many readers as harsh, especially given the "feel-good" glow that we still have about the biopsychosocial model, I think he is substantially correct in this assessment.

This book contains a lot of intellectual history—much of it probably little known to most psychiatrists but quite conceptually important to our field. Readers will find particular value in Ghaemi's detailed discussion of the work of Wilhelm Dilthey (1833–1911), a German historian, psychologist, and philosopher who was one of the originators of the concepts of causal explanation (Erklären in the original German) versus meaningful understanding (Verstehen) that play such a large role in the work of Karl Jaspers. To oversimplify, Dilthey proposed that we should separate the goal of the natural sciences (Naturwissenschaften) (e.g., physics, chemistry), which was to explain the world in terms of cause and effect, from that of the human sciences (Geisteswissenschaften) (e.g., history, sociology, and at least parts of psychology), the goal of which was to understand human behavior in terms of motivation and meaning.

This stimulating book is not without its limitations. The author is not always a disciplined writer, and some parts of the book—his treatment of Borges's view of poetry, for example—while interesting in their own right, distract from his central themes. As Ghaemi is aware, he does a better job of critiquing the biopsychosocial model in the earlier parts of the book than he does in proposing a replacement in the latter sections. Here he draws much material from his earlier book The Concepts of Psychiatry (1) and presents a loving review of the clinical and conceptual approaches to medicine of William Osler and psychiatry of Jaspers. He summarizes his recommendation as follows: "The Jasperian/Oslerian option would allow us to keep the standard scientific model of biomedicine while emphasizing a humanistic and existential orientation to the needs, values, and desires of individual human beings" (p. 210).

But this approach, although infused with wisdom and humanism, does not really tackle the issues that the biopsychosocial model at least seemed to be addressing—how to integrate the diverse etiologic factors that contribute to psychiatric illness and how to conceptualize rigorously multidimensional approaches to treatment. It is disappointing that Ghaemi does not discuss a range of exciting recent developments in the philosophy of science on approaches to complex biological systems, which are quite relevant to these issues (2–5). These works, for example, examine scientific approaches to complex, nonlinear living systems and explore various models of explanatory pluralism, from DNA to mind and culture. A number of these approaches are much more conceptually rigorous than the biopsychosocial model and might help form the foundation of a better-integrated model for psychiatry. Ghaemi's position might also have been strengthened if he more clearly differentiated between the clinical and research uses of the biopsychosocial model. In discussing my review task with my wife, a family practitioner, she was surprised at the critical views of the biopsychosocial model. "It is used widely in family medicine and is a great teaching tool, reminding the residents to consider the psychological and social influences on their cases and not just focusing on the pathophysiology," she said. While I agree with Ghaemi that the biopsychosocial model has been a failure as a scientific paradigm, it probably continues to serve a useful clinical and teaching function in psychiatry and medicine.

This book is especially suited for those who want to ponder the direction of our field and who worry about the theoretical disorientation of modern psychiatry and our resulting need for deep organizing principles. Ghaemi's grasp is wide. His book will be as much disturbing as satisfying but will provide the reader a sense of where our field has been and where it may need to go.