The Biopsychosocial Model in Anglo-American Psychiatry: Past, Present and Future?

Journal of Mental Health (2002) 11, 6, 585–594 The biopsychosocial model in Anglo-American psychiatry: 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appraise the current status tal disorder, bio-reductionist accounts should of the biopsychosocial model in Anglo- be superseded by ones which adhere to the American psychiatry.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 reductionism. 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 émigrés 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 schizophrenia was not a disease 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

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