What's wrong with the biopsychosocial model?
Nassir Ghaemi, MD, Psychiatry/Mental Health, 2010
(..)There are limits to eclectic freedom, and harms from anarchic thinking. I think this is the major problem in current psychiatry, and the BPS model is cause not cure.
uma opinião que gostei de ler,acerca da relevância do modelo bio-psico-social em psiquiatria.
[ler aqui o artigo completo]
In a previous comment, a colleague mentions that he agrees with many of my views but is puzzled by my criticism of the biopsychosocial model, which I expressed in an editorial in the British Journal of Psychiatry, and in my recent book, which is now published.
Here is the reason I dislike the biopsychosocial (BPS) model: It is merely a rationale for eclecticism, for an "anything goes" approach to psychiatry. (This is the case both in the forms advanced by thinkers like George Engel, and in its modern interpretations).
This may have been useful in the 1970s, when the model was most famously formalized by Engel, in the sense that he wanted to use it to remind physicians that there was more to illness than the body; we need to pay attention to persons too in the sense of psychology and social aspects. It was useful in the hands of its true originator - not Engel, but Roy Grinker, a leading psychiatrist in the 1950s and 1960s who used it to fight psychoanalytic dogmatism and remind psychiatrists that there was more to the mind than the Oedipus Complex. (In my book, I document this history). It is no accident it got resuscitated just at the time that psychoanalysis was about to get a death blow from two sources: DSM-III and the new psychopharmacology. Our profession latched on to the BPS model as a cease-fire between the biologists and the psychoanalysts; that's fine, but cease-fires have to end someday. We need a new constitution.
We have gone on now for three decades saying that we should all hold hands and everything will be fine. All mental illness has biological, psychological, and social aspects, we say; and this justifies those who want to emphasize the biological and ignore the rest, and those who want to emphasize the psychoanalytic and ignore the rest, and those who want to emphasize their own particular social/political agendas, ignoring the rest. By seeking to be eclectically free, we have produced an anarchy, where as Grinker once put it, psychiatry rides madly in all directions; and, this anarchy easily devolves into tyranny, where, as so many have noted, biological approaches are inappropriately used in many cases, with drugs excessively given, or psychiatric labels overly applied. And yet, the model allows tyrannies in the opposite direction: those who wish to ignore real mental disease, and the real benefits of medications, also take solace in the BPS model to pay lip service to biology while they ignore biology.
Besides these practically harmful consequences of the BPS model, it is simply wrong as a conceptual and scientific fact. Not all mental illness has equally relevant biological, psychological, and social aspects. And those who wish to cling to the BPS model mainly to defend a "humanistic" approach are mistaken: Engel in fact attacked humanism in psychiatry, and there are other better theories of medicine and psychiatry that are quite humanistic, yet more coherent and scientific than the BPS model. These are the medical humanism of William Osler and the psychiatric humanism of Karl Jaspers. (I explain these better options in more detail in my book; I may do so also in future posts if there is interest).
Our recent Medscape discussions about addiction, and sex addiction in particular, can be related to the baneful influence of the BPS model. Everyone has an opinion; some take a primarily biological approach, others a more psychosocial one, and others try various admixtures. We have no overall theory by which to adjudicate these differing views. This may be acceptable when we are ignorant, when our scientific knowledge is poor, and this may be the case in the relation to sex addiction. But this general free-for-all characterizes far too much of psychiatry, even in aspects where much more is known than many persons want to admit (e.g., the debates about bipolar diagnosis in children, or efficacy of antidepressants).
Defenders of the BPS model these days appear to me to be persons who are unhappy with biological reductionism. Fair enough; if so they should be explicit about what they want. If the debate is to be on the merits of the BPS model itself, I think we will find that errors and weaknesses abound and should not be whitewashed.
There are limits to eclectic freedom, and harms from anarchic thinking. I think this is the major problem in current psychiatry, and the BPS model is cause not cure.
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