The fall of the biopsychosocial model.

(Part Two of My Review of the book by Ghaemi.)

This section of the book is a lot less clear and less focussed. There is no transparent way to easily show how BPS has fallen. It is more the case that it has fallen, and the book articulates many ways in which this has happened.

The single biggest problem that arises is this: BPS is a broad framework with little practical utility. It permits almost any explanation. It gives no basis for deciding between options. It does not help diagnostically or therapeutically. It is neither easy to teach nor easy to use in a clinical setting.

Diagnostic and therapeutic options can be categorized within a BPS framework, but so what? Without such a framework both the diagnoses and therapeutic choices can still operate.

Let me list some of the problems discussed by Ghaemi:

1. BPS is too vague to be a useful guide for directing research. In particular it does not appeal to funding organizations. Even some conferences devoted to the subject are a little empty.

2. It is not a good teaching tool. It offers no real advantages over humanistic approaches. Many medical students forget about it as soon as possible, or are told to forget about it by other doctors, or are left with the impression its just another name for humanistic medicine. Humanism in medicine is based on Osler, who thought the patient should be engaged with and supported, and medicine was not just treating the disease. Even at medical schools influenced by Engel, considered the founder of BPS, its not taken seriously.

3. BPS in parctice is nearly all about the psychological. BPS is supposed to be about Biology, which includes psychopharmacology. Its about Psychology, which may include psychoanalysis. Its about Social issues, which can include patient support networks. However the prevailing use of this model is nearly all about the psychology, and that is heavily weighted toward psychoanalysis. While BPS is intended as an antidote to excessive reliance on biomedicine, somehow social aspects are mostly ignored in favour of psychological.

4. Lots of patients treated in a BPS approach have "treatment resistant illness". It doesn't work. Therefore the disease is not curable. In supposedly such a broad discipline, it somehow never occurs to them they are using the wrong treatments for that patient. The impression I get from Ghaemi is that even under the BPS umbrella doctors still treat patients with the tools they know. Other options tend not to be explored. This also applies to diagnosis, and is a driving force behind the psychologization of normal mental states. (We are seeing this play out in DSM-V).

5. BPS has had decades to get it right in psychiatry. Yet psychiatry is in crisis. If BPS were the answer, would we not be seeing results? (I am not sure I fully agree with this. Yes, BPS has failed, but I am not convinced it has to fail.)

To sum up, the BPS model is nice superficially, but empty in practice.

I have my own analysis as to why this is so, and what can be done about it, but I intend to leave that for my book. My own background is in systems theory amongst other things, and it is not hard to see where BPS has gone wrong, or at least that is my current opinion. In time I will expand on this but it will require a lot of work and its not my top priority for the moment.

Part III: What Next?

This starts with a discussion of the limits of evidence based medicine. More to follow.

In case anyone is wondering why I am putting so much emphasis on BPS, its the theoretical foundation for the use of CBT/GET to treat CFS and ME. While both CBT and GET are not often discussed directly in BPS terms, its alluded to frequently. GET is of course the bio- part; CBT (under a presumption of a psychosomatic illness) is the -psycho- part, and denying patients support and benefits that will enable their illness is the -social part.


Thanks for the clear summary, Alex. Interesting.

That last clause, "denying patients support and benefits that will enable their illness," is the kicker. There's so much cynicism and disrespect and cruelty behind that belief.

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