Continuing my review of Ghaemi's The Rise and Fall of the Biopsychosocial Model
This is the final and most disappointing section of the book. I think this is largely because what is attempted here is beyond the scope of a section of a book, or indeed of an entire book. Instead its a promise that there is an alternative, and some esoteric reasons as to why this is so. It is vague and full of assertions. One of the big problems is Ghaemi is fond of straw man arguments. He likes to simplify things to black and white. He wrote a section specifically defending his arguments against the straw man claim. To some degree I think he is right on that, but on occasion I think he is indeed guilty of a straw man argument in the sense that first he creates an extreme view, then argues against that.
One of the limitations of this book is that the future of BPS is only examined with respect to psychiatry.
The future: Method Based Psychiatry?
One of the things that Ghaemi claims in his book is that the BPS model is just a slogan in place of a real theory and its a slogan in support of eclecticism. Summing up his idea of a future for psychiatry (as an alternative to BPS) is the alternative of method-based psychiatry. His version of method-based psychiatry consists of two things. The first is a return to the idea of medical humanism put forward by Osler, in which doctors do not just treat disease, they treat people. He then goes on to elucidate what he means by this. The second is his view that different issues in psychiatry are best treated with specific methodologies, and that once a selection is made then that methodology should be used unless it is shown to be ineffective for the specific patient.
Ghaemi delves deeply into philosophy for his arguments. He draws on a number of philosophers, but one quote I have selected is useful for my review for a reason I am about to get to:
"From the complex of data given to me I generate the total nexus of a psychic structure in which I interpret the particular on the basis of the whole, and the whole on the basis of the particular." (Makkreel, 1992)
Now compare that with the first rule (the most important) in my rules of thumb: http://forums.phoenixrising.me/entry.php?1210-28-Rules-of-Thumb
Ghaemi goes to great lengths to reject the systems theoretic view of BPS, and in this and a number of other places he reconstructs the philosophies that underpin systems theory. A rose by any other name ...
My interpretation of his broad philsophical argument is that he is emphasizing a need for both reductionism and holistic thinking, though he usually does not use the same terminology. In rejecting BPS he argues that we should choose the appropriate level of reductionism/holism and use a psychiatric treatment method that is appropriate. He does not elucidate on how this is best done. I would argue that he is also describing a systems theoretic viewpoint, but is overly restrictive in the end.
In short, he prefers holistic thinking in analyzing and relating to a patient. He then promotes the idea of selecting a specific method in treatment. Analyze holistically (systemic, strategic) then focus on a specific treatment methodology (reductionist, tactical). This is not a lot different from what BPS could be, although BPS has failed to do this in practice.
There are other alternatives he has not discussed at all; in particular I would be very interested in his views on functional medicine.
Evidence Based Medicine
Ghaemi starts section three by talking about the limits of evidence based medicine. Given that this is a topic I intend to discuss a lot in future blogs, I don't wish to discuss this in detail here. It is enough to say that he has concluded that it is dangerous to view RCTs (randomized controlled trials) as a superior form of evidence. This can lead to a distortion of the evidence base.
Ghaemi also refers to a category mistake in psychiatry in which things are overly psychologized. He claims this includes terminology. "The schizophrenic" is referred to for example, not the person with schizophrenia. He points out that in psychiatric hospital charts there is a tendency to infer everything is psychiatric, there is nothing non-psychiatric mentioned. Every aspect of a patient is sometimes viewed from this perspective. Be warned: anything you say could mean you are psychotic ...
The Rest of Part Three
I am not going to discuss the philosophical arguments he uses in this section of the book. They are really only relevant to someone interested in the philosophy of science as it applies to medicine, and beyond the scope of a review for this forum.
Ghaemi gives an interesting account of the BPS movement. He then makes specific criticisms of its failings, and concludes it has both failed and it has no future. He presents method-based psychiatry as an alternative and implies, I think, that in general medicine a return to the humanism of Osler is almost sufficient.
I disagree on the future. One of his arguments is that BPS has failed to develop in useful ways. I concur. He then argues that in fixing these problems it would no longer be BPS, and why bother with the old name? Why not embrace the alternatives?
In some ways I disagree with this. I do think that an emphasis on people not just diseases, plus a capacity for systemic (not just reductionistic) medicine is important. In biomedicine much of this view is embraced by functional medicine, but I am less sympathetic to the idea of method-based psychiatry than I think Ghaemi would be happy with.
In the coming year or two I might give an outline as to where I think the future of biomedicine and psychiatry might be. Two things I do not agree are part of the future though: both Evidence Based Medicine and the Biopsychosocial model in their current form are not the future of medicine. Finally I will begin to discuss how this relates to CBT/GET, the PACE trial, ME and CFS. Indeed, in the long run I hope to show how the CBT/GET debacle for ME and CFS explain the deep failing of both EBM and BPS.
In the next month I have another project that may take up a lot of my time. After that I will go back to the philosophy of science arc, prior to my taking up the discussion on EBM.
Part Three: What Next?
Blog entry posted by alex3619, Feb 27, 2012.
About the Author
I am a long term ME patient with many complications. While I have pushed research advocacy since 1993, I became political around 2009. My current project is a book called "Embracing Uncertainty". Uncertainty in medical science seems anathema to too many doctors. "I do not know" is something more doctors should be honest about.