Journal of Mental (2002) 11, 6, 585–594

The biopsychosocial model in Anglo-American : Past, present and future?

DAVID PILGRIM

Lancashire Care NHS Trust & Department of Sociology, Social Policy and Social Work, University of Liverpool

Abstract The biopsychosocial model in Anglo-American psychiatry is appraised. Its content and history are described and its scientific and ethical strengths noted. It is situated in relation to competing approaches in the profession, especially an older but enduring biomedical model. The tensions provoked by the latter, in relation to ‘anti-psychiatry’, the users’ movement and ‘critical psychiatry’ are explored, as a context in which the biopsychosocial model has both emerged and been constrained. At the end of the paper, reasons for the relative lack of success of the model are discussed and its future prospects assessed.

Introduction He argued that for psychiatry to generate a fully scientific and inclusive account of men- This paper will appraise the current status tal disorder, bio-reductionist accounts should of the biopsychoso cial model in Anglo- be superseded by ones which adhere to the American psychiatry. The term insights of general systems theory, devel- ‘biopsychosocial model’ (for brevity in most oped by the biologists Ludwig von Bertalanffy of this paper ‘BPS model’) is familiar to most and Paul Weiss. This entails accepting the mental health workers. However, its formal following assumptions: status and practical success will be exam- 1. Mental disorders (like other medical con- ined, in order to assess whether or not it ditions) emerge within individuals who remains an important organising framework are part of a whole system. 2. This whole system has physical elements, for psychiatry. The historical roots of the which are both sub-personal (a nervous model will be traced and the tensions with system containing organs and networks competing currents in recent psychiatric comprised of cells, which in turn are com- theory and practice examined. prised of molecules and atoms) and supra- From Meyer to Clare: the formalisation personal. The latter entail individuals of the biopsychosocial model by 1980 existing in a psychosocial context of in- creasing complexity (two person, family, The BPS model refers to a position spelt out community, culture, society and bio- most clearly by George Engel (Engel, 1980). sphere).

Address for Correspondence: Professor David Pilgrim, Department of Sociology, Social Policy and Social Work, University of Liverpool, Liverpool L69 3BX, UK. Tel: 01772 406600; E-mail: [email protected]

ISSN 0963-8237print/ISSN 1360-0567online/2002/060585-10 © Shadowfax Publishing and Taylor & Francis Ltd DOI: 10.1080/09638230020023930 586David Pilgrim

3. The elements just described can be concep- and terminology were not readily accessible tualised as an organised systems’ hierar- and it was their expression by his followers, chy. Lower levels of organisation are which mainly established a Meyerian influ- necessary for higher ones to exist but they ence within ‘progressive’ psychiatric think- are not sufficient to describe, or explain, ing each side of the Atlantic. their nature. With each higher level of Under the leadership of Aubrey Lewis, at organisation emergent characteristics ap- the Institute of Psychiatry in London, by the pear, which are not present at lower lev- 1970s, the BPS model was established as a els. Holistic epistemologies should re- form of psychiatric orthodoxy. Prior to 1980, flect this complex ontology and thereby a BPS approach was being reinforced by a avoid . number of Institute staff, including Goldberg, 4. Attempts at accounting for mental disor- Clare, and Shepherd, though the last of these, der, which only refer to sub-personal fac- maybe because of his hostility to psychoa- tors (the biomedical model in psychiatry), nalysis, used the term ‘biosocial model’. As will be reductionist. Engel (and others a further indication of the BPS model reach- advocating the BPS model) note two con- ing the status of a temporary orthodoxy, at sequences of reductionism. First, diag- least in London, it came to gain the support of nostic and etiological accounts from a collaborating psychiatric social workers and biomedical approach will be partial and clinical psychologists (Goldberg & Huxley, thus scientifically inadequate. Second, 1992; Falloon & Fadden, 1993). It was also such reductionist accounts may well of- reflected in the work of some sociologists, fend humanistic sensibilities and psychia- who were becoming independent methodo- try might accrue a dehumanising reputa- logical leaders in the interdisciplinary project tion. of ‘social psychiatry’ (Brown & Harris, 1978). These assumptions, summarised from the Ironically, Meyer may have had less direct work of Engel, reinforced a trend within influence in his host country, though he was academic psychiatry, begun early in the twen- not dismissed or forgotten (Stone, 1997). tieth century by the Swiss psychiatrist Adolf Scull (1990) documents how even some of Meyer, who lived out his professional career Meyer’s most dedicated early US followers, in the USA after 1893. His collected works such as Henry Cotton, quickly relapsed into were published two years after his death a crude bio-determinism in their clinical work. (Meyer, 1952). According to Gelder (1991), Gelder (ibid) speculates that Meyer’s lesser Meyer’s work is ‘great but difficult to dis- impact in the USA was because of the dis- cern. This is because his ideas have become placement of his ideas by psychoanalysis, so much part of the basic structure of British which has enjoyed alternating periods of he- clinical psychiatry.’ Meyer gained a substan- gemony with bio-determinism. tial theoretical influence in British academic Meyer integrated ideas about science and psychiatry, via the work of several acolytes, mind developed within British philosophy who spent time with him in Baltimore and and evolutionary theory in the nineteenth then went on, or back, to Britain. Henderson century, indicating that Anglo-American psy- & Gillespie (in Scotland after the First World chiatry developed through mutual influences War) and Lewis (in England after the Second criss-crossing the Atlantic. As with other World War) were particularly important in intellectual developments in the Anglophone this regard. However, Meyer’s writing style academy, in is not unusual for é migrés to The biopsychosocial model in psychiatry 587 fulfil this carrier-cum-developer role north American version of the BPS model, (Anderson, 1969). With regard to intellec- Anthony Clare was reflecting on a turbulent tual labour in psychiatry, Meyer (Swiss) and period in psychiatry, which culminated in its Lewis (Australian) are good examples of this global crisis. With the appearance of ‘Psy- phenomenon. Another important figure in chiatry in Dissent’ (Clare, 1976), psychiatry relation to the BPS model discussed below, was emerging from a decade of sustained Anthony Clare, was an Irishman in Great attack from, what came to be known as, ‘anti- Britain. psychiatry’. The latter term came to sub- Having distilled his views from British sume, for proponent and opponent alike, any intellectual developments, Meyer offered two intellectual challenge to a biomedical model. core strictures about mental illness. First, he This included questions about: the logical argued that the elucidation of a patient’ s status of mental illness; the intelligibility of problems must be in relation to their personal madness; the dehumanisation of institutional history, not merely their current mental state. care and a biomedical regime; and the re- This made him wary of a mechanistic, rule- framing of mental illness as deviance. Psy- following, Kraepelinian approach to diagno- chiatry had become a polarised field of de- sis, which has resurfaced robustly recently in bate between what Roth (1973) called ‘psy- the Diagnostic and Statistical Manual system chiatry and its critics’. (see later). For Meyer, the careful under- While this paper is not about ‘anti-psychia- standing of particular cases in their biographi- try’, the cultural reputation of the latter and cal context needed to be privileged over at- its standing in the psychiatric profession are tempts at fitting patients’ symptoms, relevant. ‘Anti-psychiatry’ forced psychia- Procrustean-style, into pre-existing diagnos- trists to engage with an attack upon their tic categories. orthodox theory and practice, which stimu- Second, for Meyer, mental illness repre- lated intellectual debate within the profes- sented the accumulation of the patient’s ‘un- sion. At first, senior medical reactions were healthy’ reactions to their environment angry and dismissive in their short responses (Henderson & Gillespie, 1927). He argued to ‘ anti-psychiatry’ (e.g. Hamilton, 1973; that was not a but ‘a Roth, 1973). With the passage of time, psy- congeries of individual types of reaction hav- chiatric refusals of ‘anti-psychiatry’ became ing certain general similarities’ . Meyer’s longer and more considered, with telling ti- logic was that biological susceptibility (due tles, such as, ‘Reasoning About Madness’ to inherited or acquired neurophysiological (Wing, 1978), ‘The Reality of Mental Illness’ disturbance) may be important but it is not (Roth & Kroll, 1986) and, the more ambigu- sufficient to explain the emergence of why ous, ‘Psychiatry in Dissent’ (Clare, 1976). this person is mentally ill, in this way, at this Along with Engel’s work, Clare’s represented point in their lives. As a consequence, Meyer’s a form of inclusive compromise (a ‘portman- model was known as ‘psychobiology’. Its teau model’ (Baruch & Treacher, 1978)) ly- emphasis upon the lack of sufficiency of bio- ing between the biomedical model and radi- reductionism and upon the biographical and cal social critiques of psychiatry. The cred- social context of a person’s functioning pre- ibility and influence of the BPS model after figured the systemic position taken by Engel. the 1970s will be considered below. But At the time that Engel was spelling out his before that, its conditions of possibility need 588David Pilgrim to be examined in a brief historical excursion. bio-determinism both reflected and contrib- uted to the ‘zeitgeist’ of eugenic thought in The biopsychosocial model in a western intellectual culture. Another histo- longer historical context rian of the period notes that by 1900, ‘psy- chiatry looked on itself with uncritical mat- The BPS model is not merely one of many ter-of-factness as natural-scientific enlight- competing possibilities, within the contested enment, as a fight against demonologic and field of mental illness and psychiatry. It has other social superstitions and for the rights of not been simply constructed, intelligently, the mentally ill…’ (Doerner, 1970:292). but whimsically, by those with an eclectic However, this self-confidence was soon mentality. What increased the probability of undermined by the ‘ shellshock problem’ epistemological inclusiveness was the cred- emerging after 1914. Stone (1985) notes that ibility problem inherent to psychiatry as a there was a fundamental incompatibility be- medical specialism. This problem did not tween a eugenic view about lunacy, the legacy manifest itself immediately but emerged even- from Victorian asylum doctors, and the grim tually under conditions of warfare. reality of officers and gentleman and work- By the turn of the twentieth century, psy- ing class volunteers (‘England’s finest blood’) chiatry was still relatively new. The term breaking down with predictable regularity in ‘psychiatry’ first appeared in Britain only in the trenches of the ‘Great War’. To offer a 1858. Prior to that there were only ‘mad- eugenic explanation for the newly and, at doctors’ or ‘alienists’ and many of the large first, confusingly, described neurotic reac- new asylums were run by ‘lay’ (i.e. non- tions, witnessed in these traumatised sol- medical) administrators. In the Victorian diers, was tantamount to treason. Not only period, fledgling psychiatry was faced with was the monopoly of biodeterminism now two challenges. One was to wrest political broken and, for a while abjured, other modes control of the asylum system from lay admin- of psychiatric thinking were made possible istrators. Another was to construct a credible (Armstrong, 1980). Neurosis, not just psy- knowledge base to underpin a form of medi- chosis, now came within the ambit of psy- cal authority over lunacy. These two chal- chiatry and psychoanalysis was finally of- lenges were met politically by overlapping fered some legitimacy after its pre-war dis- strategies (Scull, 1979). One was to develop missal by the leaders of psychiatry and neu- a rhetoric of justification for the professional rology. project of psychiatry. Scull cites an editorial A year after the end of the Great War both from the ‘Journal of Mental Science’ (the the British Psychoanalytical Society and the former title of the ‘British Journal of Psychia- Medical Section of the British Psychological try’) in 1858, which, in two sentences, cap- Society were established. This moment could tures the essence of this rhetoric: ‘Insanity is be read as the beginnings of a protracted purely a disease of the brain. The physician heavyweight contest between biological psy- is now the responsible guardian of the lunatic chiatrists and medical psychotherapists. and must ever remain so.’ However, with the develop ment of the For over 50 years this position remained in Tavistock Clinic, such a simple polarisation the ascendancy in debates about lunacy. In- did not become evident, at least at first. deed, the asylum system was taken over Armstrong (ibid) notes that initially the Clinic successfully by medical superintendents and favoured ‘a unified psycho-somatic approach The biopsychosocial model in psychiatry 589 to diagnosis and treatment’ and that the Clin- After wars, biologically dominated work tends ic’s founder, Crichton Miller, ‘believed that to return to ‘business as usual’, both in clini- emotions, sepsis, the endocrines and blood cal practice and in its influence on the dis- circulation all had inter-dependent effects on course of politicians. A good recent example mental stability’. Thus even within an in- of this is in relation to government policy creasingly psychodynamic view, eclecticism makers construing ‘ treatment’ narrowly to was evident and the Meyerian project in mean psychotropic drugs, when reviewing Baltimore already had resonances in London options for compulsory community powers. by the early 1920s. The above describes the historical back- Between the world wars a compromise was drop to the work of those like Meyer and worked out between medical psychotherapy Engel in the USA and Lewis and Clare in and biological psychiatry or the hostile fac- Britain. This work has offered psychiatry a tions eschewed one another. This was true in challenge, but of greater importance, it has both US and British psychiatry and eclecti- also offered it a rescue package. The fate of cism provided a middle position to adopt this challenge and opportunity will now be within clinical practice or as part of the pro- examined. fession’s rhetoric for external consumption. An example of an ambivalent middle posi- The fate of the biopsychosocial model tion was some of the work of Aubrey Lewis after 1980 in the early 1930s, which, despite its eclectic bent, focused on genetics and remained for a Having addressed the history of the BPS while within the discour se of eugenic s model, its more recent standing will be ap- (Gottesman & McGuffin, 1996). praised. Four summary points can be made Earlier, Gelder’s point about psychoanaly- about the promise offered by the model over sis in north American psychiatry was noted. the past 20 years: There, the tension within the American Psy- 1. If a BPS model was applied thoroughly in chiatric Association, between biological psy- all cases, then psychiatry might enjoy a chiatry and psychoanalysis, has produced an boost in its acceptability to its recipients. organisational dynamic, which has been less 2. In day-to-day clinical practice the model evident in Britain. However, even in Britain, also creates the option of seamlessly com- as far as government preferences are con- bining physical and psychological treat- cerned, a policy pattern can be discerned of ments, without undermining the doctor’s oscillation. Around times of major wars diagnostic authority. Unlike many pro- psychodynamic doctors are favoured. For fessional and user critics of psychiatry, example, J.R. Rees, the director of the the BPS model does not object to diagno- Tavistock Clinic was appointed as head of sis in principle; it only suggests that this the Army psychiatric service in 1939 (Rees, process should privilege the patient and 1945). their longitudinal context, over the medi- Another example of this oscillation, imme- cal categories applied to them. diately after the First World War, was of 3. The model’s inclusive, multi-factorial or asylum doctors being so out of favour, that holistic advantages create the possibility none were invited to sit on the Macmillan of an approach to mental health problems, Commission (1924–1926), which preceded which could be both scientific and hu- the 1930 Mental Treatment Act (Stone, 1985). manistic. 590David Pilgrim

4. Critics denigrating psychiatry or even de- ‘anti-psychiatrists’ did not disappear, even manding its abolition, from ‘anti-psychia- though their original form petered out within try’ or the users’ movement, could be debates about mental health in the 1970s. offered a credible riposte and their attacks They were neither definitively refuted (by defused. Virtually all of the disquiet cre- those like Hamilton and Roth) nor were they ated by psychiatry since the Second World permanently defused by partial incorpora- War has emanated from a constellation of tion (by those like Clare). The political factors within a reductionist biomedical concerns of anti-psychiatry have been re- orthodoxy. These concerns from the crit- cycled in criticisms from disaffected users, ics of psychiatry have focused on: a pre- who now constitute a new social movement sumptuous attitude about biological aeti- (Rogers & Pilgrim, 1991). They have also re- ology; a singular emphasis on biological surfaced within a newer post-modern profes- treatments; a dehumanising and paternal- sional dissent of ‘critical psychiatry’ (Bracken istic attitude towards patients; and the & Thomas, 1998) and in continuing north privileging of the psychiatrist’ s right to American attacks upon the biomedical model treat over the patient’ s right to liberty. from within a realist, rather than a post- This psychiatric professional agenda has modern, paradigm (Breggin, 1991; Ross & constituted a wide target to hit by critics Pam, 1995). This suggests that a dialectical and the BPS model provides the means to opposition provoked by the biomedical model significantly reduce its size. has not produced a self-evident synthesis in However, just as the early twentieth cen- the BPS model. tury did not witness a neat dichotomy be- Third, those favouring a holistic model tween psychodynamic and biological stances, have recently expressed a concern that psy- the status of the BPS model in the early chiatry is simply becoming neuropsychiatry, twenty-first century is by no means clear. with the BPS model losing its earlier gains: Superficially, it is tempting to describe it as ‘As mental hospital gives way to acute an accepted orthodoxy and even to attribute it district general hospital and community fa- with a pre-eminent status, but a number of cilities, are the psychological aspects of dis- cautions can be identified. ease being reabsorbed within the very core of First, the pluralism evident in modern men- medicine or is psychiatry slowly being fil- tal health services may be driven more by tered and the social domains it has for two pragmatism than by the BPS model. Indeed, centuries so painstakingly valued and en- it might be more accurate to account for the dorsed being remorse lessly discarded?’ admixture of drugs, ECT and psychological (Clare, 1999: 111). interventions in services as the outcome of Clare’s lament points to a fourth reason to different disciplines (and groups within them), conclude that the BPS model is not a stable who favour different approaches to mental orthodoxy within psychiatry. History sug- health work, negotiating a form of mutual gests that the biomedical model is a hardy tolerance (Goldie, 1977). In these organisa- perennial. Instead of the ‘shell-shock prob- tional circumstances, it is easy to confuse lem’ permanently suppressing a crude pragmatic co-existence, within a variegated biodeterministic position, in the wake of Vic- and negotiated order of professionals, with torian eugenics, it merely created the condi- genuine evidence of a shared BPS orthodoxy. tions of accommodation. Despite the consti- Second, many of the criticisms made by the tution of the Macmillan Committee, the 1930 The biopsychosocial model in psychiatry 591

Mental Treatment Act did not ensure that the Kallmann emigrated and continued his work influence of psychotherapy prevailed, in the in the USA. Their British collaborator, Eliot mainstream of the profession, and institu- Slater, returned to the Maudsley after the tional psychiatry and physical treatments war, having worked in Munich since 1934 continued to predominate. (Gottesman & McGuffin, 1996). A biological model favours methods of Given this pattern of long term survival of treatment which are well suited to the imper- the biomedical model, in the face of sporadic sonal and, if required, coercive management and cumulative attacks from a variety of of madness. Moreover, doctors may instinc- parties, it is not surprising that, episodically, tively favour a biomedical model. In a sense it is re-asserted in very confident terms. it is odd when psychiatrists do not advocate a Clare’s concern noted above refers to a typi- ‘medical model’; after all they are medical cal example of this in the work of Samuel practitioners. Medical socialisation empha- Guze. Here the latter tells us that: sises somatic pathology and encourages the ‘...what is called psychopathology is the role of doctors as chemotherapists with a manifestation of disordered processes in vari- prescription pad. Drug company research, ous brain systems that mediate psychological marketing and sponsorship of psychiatric functions.... By taking into consideration training events reinforce these medical norms. genetic codes and epigenetic development, Versions of a taken-for-granted certainty guided and shaped by broad-ranging envi- about genetically-shaped, neuro-physiologi- ronmental influences, only some of which cal processes pepper the writings of biologi- are now recognised and understood, biology cal psychiatrists (Ross & Pam, 1995). Bio- clearly offers the only comprehensive scien- logical certainty is captured in Gerard’s phrase tific basis for psychiatry just as it does for the ‘no twisted thought without a twisted mol- rest of medicine ...’ (Guze, 1989: 317/318). ecule’ (Abood, 1960) or by ‘strange people After 1980, this sort of biological strange substances’ (van Praag, 1977). These triumphalism was symptomatic of a ‘return presumed biological truisms lead to junior to medicine’ in the profession. This trend is psychiatrists learning biodeterminism ‘by described here by Fernando (1992) who ar- assumption’ (Kemker & Khadivi, 1995). gued that his profession in Britain had re- Biological assumptions permeate a psychiat- cently: ric cultural tradition, dating back to the salad ...turned in on itself, going back to the days of Victorian eugenics, which young traditional basics of medicine – emphasising doctors join, contribute to and reproduce. biological and genetic aspects of health and Not only did biological psychiatry survive illness, concentrating on drug therapy (as an the challenge of ‘ shell-shock’ in the First undeniably ‘medical’ form of treatment) de- World War, it even survived the ignominy of vising more and more specialisms and refus- its association with Nazi eugenics in the ing to address serious problems (such as Second. For example, the twin studies of racism) within its professional practices. ‘schizophrenia’ in 1930s Germany, by Franz (Fernando, 1992:9). Kallmann and his mentor Ernst Rudin, still This ‘return to medicine’ was evident on a underpin respectable Anglo-American re- larger scale in the USA, with the revisions of search in psychiatric genetics (Marshall, the American Psychiatric Association’s Di- 1990). Rudin was tried and found guilty at a agnostic and Statistical Manual. The latter de-Nazification tribunal in Nuremb erg. shifted from an aetiological emphasis (fa- 592David Pilgrim voured by the BPS model) to one of non- form of integrationism in response to the four committal neutrality about causality and a models they summarised. However, the op- focus on current behavioural features. This tion of ‘ picking from the shelf’ the BPS shift might appear to be inoffensive to all- model, and giving it a chapter of its own, was comers, as it seems to avoid any partisan not taken. stance. However, its advocates make an The same is true of ‘Mind , Meaning and explicit link between DSM and the legiti- ’ by Bolton & Hill (1996). macy of a ‘medical model’, which can now Despite a long analysis of determinism and rescue the term from the pejorative connota- agency and the nature of explanations in tions created by ‘anti-psychiatry’. Here, for psychiatric theory and practice, they make no example, is the view of two leading advo- mention of the BPS model, or of the tradition cates of DSM: of intellectual labour, which created and de- ‘DSM-III was a landmark in the develop- veloped it. Bolton & Hill discuss the work of ment of psychiatric classification, drawing Guze (critically) but not advocates of the on the best available research from the pre- BPS model. The point here is not about the ceding decades and placing psychiatry firmly merits of these two books but the relative back in the medical model of basing treat- silence, which descended after 1980, on dis- ment decisions on diagnosis....’ (Blacker & cussions about explanatory models in psy- Tsuang, 1999: 70, emphasis added). chiatry, in relation to the BPS approach. A fifth and final indication of a losing battle Whilst the recent texts focusing on models for the BPS model is its relative lack of of explanation within psychiatry fail to for- visibility within those psychiatric texts after mally recognise the continuing significance 1980, which set out explicitly to discuss of the BPS model, the latter still has a pres- models of causality in psychiatry. Take two ence in research reports. This may reflect a examples, the first an introductory primer residual inter-disciplinary influence, even if, about psychiatry and the second a more schol- in overall terms, it has declined in epistemo- arly philosophical analysis. Tyrer & Stern- logical significance. For example, an berg (1987) in their ‘Models for Mental Dis- interactionist position, in which biological, order’ give a clear outline of just four models, psychological and social factors are explored, which they call ‘disease’, ‘psychodynamic’, can be found in relation to reports of diverse ‘behavioural’ and ‘social’. Of these, the last topics. These include: personality disorder is the nearest to a BPS model (citing work (e.g. Paris, 1996); neuro-psychoanalysis (e.g. from the Institute of Psychiatry). Kaplan-Solms & Solms, 1996); attachment What is noteworthy about the final chapter theory (e.g. Cassidy & Shaver, 1999); institu- of the book is that it offers a critique of the tional living in children (e.g. Rutter, 2001) dangers of partiality entailed in being se- and female depression (e.g. Kendler et al., duced by one or other of the four models 1993; Brugha et al., 2000). summarised. By the end of the book, the Whilst these topic-based reports do not set authors actually construct a persuasive argu- out primarily to champion the BPS model, ment for a sort of BPS model. However, at no they do reflect its remaining impact on psy- point do they use this term, or a variant, nor chiatric research. Nonetheless, the ‘return to do they allude to the long respectable history medicine’, ‘the decade of the brain’ and the of such an approach in academic psychiatry. more recent absence of the BPS model in Their discussion generates an appeal for a texts about explanatory models casts a seri- The biopsychosocial model in psychiatry 593 ous doubt upon its future. If the BPS model’s tween bioreductionsim and its opponents, relevance in debates about causality in psy- manifest first in ‘anti-psychiatry’, then in the chiatry has become shady and ambiguous, mental health service users’ movement and, the biomedical model has retained a clear more recently, in ‘critical psychiatry’, may salience. For example, Shorter (1998) com- lead to a re-discovery of the biopsychosocial ments, early in the pages of his history of model and a re-affirmation of its merits. psychiatry that: Alternatively, we may be witnessing the slow ‘…if there is one central intellectual reality terminal decline of a late twentieth century at the end of the twentieth century, it is that casualty of psychiatric debates and the emer- the biological approach to psychiatry – treat- gence of newer forms of political and episte- ing mental illness as a genetically influenced mological resolution between ‘psychiatry and disorder of brain chemistry – has been a its critics’. smashing success.’ (Shorter 1998: vii). It is this contrast in standing and confi- Acknowledgements dence, between the biomedical model and the BPS model, which now raises a question A version of this paper was presented at the about the viability of the latter. The annual conference of the Critical Psychiatry bioreductionist certainty of Shorter (and of Network (April 2002, Birmingham). I am Guze noted earlier) suggests that the pro- grateful to Dr Duncan Double, Dr John grammatic statement from the Journal of McKenna and Prof. Anne Rogers for their Mental Science in 1858, cited by Scull (1979), comments on an earlier draft and to the well- was indeed prescient. It seems that the bio- referenced feedback from one anonymous medical self-confidence at the end of the referee. Victoria period, noted by Doerner (ibid), had returned a century later and those in the References lineage of Meyer and Engel may now be in retreat. Abood, L. (1960). A chemical approach to the problem This paper has summarised the content and of mental disease. In D. Jackson (ed). The Etiology history of the biopsychosocial model in psy- of Schizophrenia . New York: Basic Books Anderson, P. (1969). Components of the national chiatry and appraised its current status and culture. New Left Review 50, July/August. prospects. The acclaimed intellectual re- Armstrong, D. (1980). Madness and coping. Sociology source of general systems theory and the of Health and Illness 2, 3, 293–313. acknowledged reputation of its early advo- Baruch, G. & Treacher, A. (1978). Psychiatry cate, Adolf Meyer, underpin the model. It Observed. London: RKP. Blacker, D. Tsuang, M.T. (1999). Classification and offers professional advantages for psychia- DSM-IV. In A.M. Nicholi (ed), The Harvard Guide try and humanistic benefits to mental health to Psychiatry, (3rd Edition). London: Belknap. service users. At times, it even engenders Bolton, D. & Hill, J. (1996). Mind, Meaning and genuine inter-disciplinary cooperation. De- Mental Disorder: The Nature of Causal Explana- spite these professional, scientific and ethical tion in and Psychiatry. Oxford: Ox- ford University Press. virtues, to date its promise may not have been Bracken, P. & Thomas, P. (1998). A new debate in fully realised. Latterly it has been kept in the mental health. OpenMind 89, 17. shadows by a return to medicine and the re- Breggin, P. (1993). Toxic Psychiatry London; Fontana. ascendancy of a biomedical model. Brown, G. & Harris, T. (1978). The Social Origins of It may be that the unresolved conflict be- Depression. London: Tavistock. 594David Pilgrim

Brugha, T., Wheatley, S., Taub, N.A., Culverwell, A., Kernker, S.S. & Khadivi, A. (1995). Psychiatric edu- Friedman, T., Kirwan, P., Jones, D.R. & Shapiro, cation: learning by assumption. In C.A. Ross & A. D.A. (2000). Pragmantic randomised trial of ante- Pam (eds), Pseudoscience in Biological Psychia- natal intervention to prevent post-natal depression try: Blaming the Body. New York: Wiley . by reducing psychosocial risk factors. Psychologi- Marshall, J.R. (1990). The genetics of schizophrenia: cal Medicine, 30, 1273–1281. axiom or hypothesis? In R.P Bentall (ed), Recon- Cassidy, J. & Shaver, P.R. (1999). Handbook of structing Schizophrenia. London: Routledge. Attachment: Theo ry, Resea rch and Clinic al Meyer, A. (1952). The Collected Papers of Adolf Applications, New York: Guilford. Meyer. Baltimore: Johns Hopkins University Press. Clare, A. (1976). Psychiatry in Dissent. London: Paris, J. (1996). Social Factors in the Personality Tavistock Disorders, Cambridge, MA: Cambridge Univer- Clare, A.W. (1999). Psychiatry’s future: psychological sity Press. medicine or biological psychiatry? Journal of Rees, J.R. (1945). The Shaping of Psychiatry by War . Mental Health, 8, 2, 109–111. New York: Norton. Doerner, K. (1970). Madmen and the Bourgeoisie. Rogers, A. & Pilgrim, D. (1991). ‘Pulling down Oxford: Blackwell. churches’: accounting for the British mental health Engel, G.L. (1980). The clinical application of the users’ movement. Sociology of Health and Illness, biopsychosocial model. American Journal of Psy- 13, 2, 129–48. chiatry, 137, 535–544. Roth, M. (1973). Psychiatry and its critics. British Falloon, I. & Fadden, G. (1993). Integrated Mental Journal of Psychiatry , 122, 374. Health Care. Cambridge: Cambridge University Roth, M. & Kroll, J. (1986). The Reality of Mental Press. Illness. Cambridge: Cambridge University Press. Fernando, S. (1992). Psychiatry, OpenMind, 58, 8–9. Ross, C.A. & Pam, A. (eds) (1995). Pseudoscience in Gelder, M. (1991). Adolf Meyer and his influence on Biological Psychiatry: Blaming the Body. New British psychiatry. In G.E. Berrios & H. Freeman York: Wiley . (eds), 150 Years of British Psychiatry 1841–1991. Rutter, M. (2001). Specificity and heterogeneity in London: Gaskell/Royal College of Psychiatrists. children’s responses to profound institutional pri- Goldberg, D. & Huxley, P. (1992). Common Mental vation. British Journal of Psychiatry , 179, 97–103. Disorders. London: Routledge. Scull, A. ( 1979). Museums of Madness. Goldie, N. (1977). The division of labour among Harmondsworth: Penguin. mental health profession - a negotiated or an im- Scull, A. (1990). Desperate remedies: a Gothic tale of posed order? In M. Stacey & M. Reid (eds), Health madness and modern medicine. In R.M. Murray and the Division of Labour. London: Croom Helm. and T.H. Turner (eds), Lectures on the History of Gottesman, I.I. & McGuffin, P. (1996). Eliot Slater and Psychiatry. London: Gaskell/ Royal College of the birth of psychiatric genetics in Great Britain. In Psychiatrists. H. Freeman and G.E. Berrios (eds), 150 Years of Shorter, E. (1998). A History of Psychiatry: From the British Psychiatry: Vol II, The Aftermath. London: Era of the Asylum to the Age of Prozac . Chichester: Athlone. Wiley. Guze, S.B. (1989). Biological psychiatry: is there any Stone, M.H. (1997). Healing the Mind: A History of other kind? Psychological Medicine, 19, 315–323. Psychiatry from Antiquity to the Present. New Hamilton, M. (1973). Psychology in society: end or York: Norton. ends? Bulletin of the British Psychological Society, Stone, M. (1985). Shellshock and the psychologists. In 26, 185–9. W.F. Bynum, R.Porter & M. Shepherd (eds). The Henderson, D.K. & Gillespie, R.D. (1927). Textbook of Anatomy of Madness (Vol 2) . London: Tavistock. Psychiatry. London: Oxford University Press. Tyrer, P. & Sternberg, D. (1987). Models For Mental Kaplan-Solms, K. & Solms, M. (1996). Psychoanalyti- Disorder. Chichester: Wiley. cal observationson a case of frontal-limbic disease. van Praag, H.M. (1977). The significance of dopamine Journal of Clinical Psychoanalysis, 5, 405–438. for the mode of action of neurol eptics and Kendler, K.S., Kessler, R. & Neale, M. (1993). The pathogenesis of schizophrenia. British Journal of prediction of major depression in women: toward Psychiatry, 130, 463–474. an integrated etiologic model. American Journal of Wing, J.K. (1978). Reasoning About Madness . Ox- Psychiatry, 150, 1139–1148. ford: Oxford University Press.