I found this book confused. Nassir Ghaemi's argument is that modern psychiatry has no overarching conceptual structure and instead is eclectic, accepting that "all theories are possible and all perspectives are valued". He is looking for an antieclectic, antidogmatic way of thinking for psychiatry. Unfortunately he rejects the biopsychosocial model which, in my view, provides him with just that solution.
I am not saying that the biopsychosocial model is not interpreted in an eclectic way at times. I understand what Ghaemi means when he says that modern psychiatry is eclectic. In particular, biological and psychotherapeutic treatments may be combined without any systematic theory to support such a therapeutic strategy. There is also commonly a split in the etiological understanding of major psychotic illness, which is seen as being biological in origin, and more minor, neurotic illness, which is seen as having psychosocial causes.
The problem is that Ghaemi includes the theoretical models of George Engel and Adolf Meyer under eclecticism. True, neither have had the impact on mainstream psychiatry that they should have had. The biopsychosocial model has only ever been a minority interest. Meyer himself, towards the end of his life, recognised that he failed to be explicit about his psychiatric system.
I actually agree with Ghaemi that eclecticism has outserved its usefulness. My proposal is that psychiatry return to the biopsychosocial model and make it more central to its thinking. Ghaemi misses this possibility because he views the biopsychosocial model as eclectic, which he wants to avoid.
I think I can understand how this muddle arises. The biopsychosocial model inevitably embraces the uncertainty of human action, because this is the nature of people's behaviour. Our conceptual bias, on the other hand, favors clarity and certainty, whereas the biopsychosocial model is just seen as too vague by comparison. However, this defensiveness is not much help if it flies in the face of the facts. Mental states are still required to account for much human behaviour that is not caused by brain dysfunction. A meaningful worldview requires understanding of the patient as a person, which may help to elucidate the reasons for human action but cannot provide the finality of causes.
Ghaemi's intentions may be valid, but I wonder about the consistency of his clinical practice from his other writings. For example, he is one of the psychiatrists who has done most to promote the concept of bipolar depression. There was a time when psychiatry would not have made so much of the difference of whether depressed people also had manic episodes or not. With the development of mood stabilizing medication, this has come to matter more and the concept of bipolar disorder has even been broadened to make more people eligible for these new medications. From his publications on bipolar depression, Ghaemi seems to think that this is a good thing. He says he wants to accept the biological reality of mental illness without being biologically reductionistic, but, as far as I can see, he merely encourages a medical humanism with what is really an inappropriate, biologically reductionistic model of mental disease.
Please do not misunderstand me. I am encouraging the integration of mind and body, not their separation. The brain is the origin of the mind. We need to acknowledge that minds are enabled but not reducible to brains. The trouble is that modern psychiatry does not do this enough. I don't think Nassir Ghaemi does either, although his book is helpful in raising these issues and pointing out the need for consistency in our answers to them.
I think the reason that many psychiatrists retreat into eclecticism is the conflict created by the split between biomedical and biopsychosocial models. However, this separation has always been present in modern psychiatry since its origins in the asylum. It's just that the balance has always been in favor of the biomedical, and it needs to be shifted more to the biopsychosocial. I agree with Ghaemi that this issue shouldn't be avoided. However, I don't think his solution is internally consistent. In fact, it's still eclectic.
© 2010 Duncan Double
Duncan Double, Consultant Psychiatrist and Honorary Senior Lecturer, Norfolk Mental Health Care Trust and University of East Anglia, UK; Website Editor, Critical Psychiatry Network.
Response by Nassir Ghaemi, received June 30, 2010
Authors have a common experience: one spends years researching and writing a book; then a reader spends days at most, sometimes only part of a day, speed-reading the material. In response to some comments, one is tempted to say: please read the book. Here I will not reprise the arguments that are laid out in detail in the book; indeed, the reason I wrote a book-length work is because such arguments need careful scholarly citation and gradual expression. Specific examples where the book addresses comments in the review are as follows: It is claimed that the biopsychosocial model was "a minority interest," yet it became part of the standard criteria of medical education by US medical schools and part of the standards of passing the oral psychiatry boards. The reviewer stresses the importance of "meaning" for support of the BPS model, while I have specifically critiqued – in an extensive analysis of the distinction between meaning (Verstehen) and causation (Erklaren), especially in the work of the philosopher Wilhelm Dilthey. The reviewer criticizes "merely" supporting medical humanism, while in the book I provide an extensive philosophical and historical rationale for Osler's medical humanism model. In contrast, I show, with citations including Engel's own works, that the BPS model is anti-humanistic, both in its origins and in its results.
The reviewer is perplexed about how anyone could be non-reductionistic, or philosophically-oriented, and care about bipolar depression. The mere perplexity demonstrates the problem. I do not fit into the comfortable eclectic, postmodernist worldviews of such critics: Either one is a biological reductionist (whose motivations are power and money, with little knowledge or background in philosophy or history) or an enlightened postmodernist (interested in the humanities and philosophy, and committed to the repressed and marginalized). How can I be adept in philosophy and the humanities, and yet not be one of the anti-biological crowd?
The specifics are as follows: "Bipolar depression" is a new concept; most of what we now call depression previously was termed "manic-depression," at least in Kraepelin's approach. The term bipolar disorder is new, and involves dividing Kraepelin's manic-depression into one small part (mania with or without depression, or bipolar disorder) and one large part (so-called major depressive disorder, MDD). I and others have been trying to teach contemporary psychiatry that this change, which happened in 1980 with DSM-III, was not eternal, and that it has been thrown into doubt scientifically by nosological research on diagnostic validators (symptoms, genetics, course, and treatment response) in the intervening decades.
This reviewer's perplexity is a good example of the postmodernist assumptions (described in the book) of many psychiatric critics. He assumes that the broadening of the bipolar diagnosis is bad, and that it is simply driven by the availability of medications. The scientific evidence and psychiatric history itself is not mentioned.
I wrote this book to show that psychiatry is confused: a simple reductionism will not do -- I agree -- but the alternative, this eclectic mish-mash of anti-biological ideology and postmodernist assumptions, is no better. The BPS model has fostered this eclectic state of affairs. Readers can judge for themselves whether my critique of that model is historically and conceptually sound. As for the alternative, which I have written about in detail here and in more detail previously (The Concepts of Psychiatry), readers can examine the rationale for William Osler's medical humanism and a method-based psychiatry (derived from Karl Jaspers), which I show is not eclectic at all, while also not biologically reductionistic. This possibility is outside of the mindset of bromidic anti-biological critics, which is exactly why new ways of thinking are needed.
© 2010 Nassir Ghaemi
Reply by Duncan Double, received July 13, 2010
I'm sorry that Nassir Ghaemi does not think I gave his book the time of day. I agree there was a time when psychiatry was more pluralistic. I am not undermining his medical humanism. I also agree that our argument should be debated at an academic rather than polemical level.
I'm just not convinced by his point that Engel was saying there was no need for the humanities. This may be because of a misunderstanding about the definition of "science". Engel had a broad understanding of science, which was what Meyer called a commonsense view. He recognized the limited value of the biomedical model within its own sphere. However, to use a quote from Engel that Ghaemi himself cited "But to do otherwise is to be unscientific; to advocate doing otherwise is to promote dogma and become unscientific."
Ghaemi cannot understand the need for the biopsychosocial model. He even thinks it is not humanistic, because, for example, it may tend to encourage the blaming of parents for causing mental illness. However, it is not anti-materialistic, which I think is what he fears. I'm happy to debate the nosological basis for psychiatric diagnoses, such as bipolar depression, but we need to avoid the reification of diagnostic concepts in psychiatry.
I would also quibble that my views are postmodernist. My theoretical position is no different from the biopsychosocial model of Engel, or even that of Philippe Pinel's traitement moral. More seriously, it's a mistake to call me anti-biological. Let's concentrate on stating what we're in favour of rather than what we're against. I am not wanting to polarize debate about psychiatry, vying to be the more anti-eclectic. I just do not think that Ghaemi's grand solution is valid. As he says, readers can decide for themselves on these issues.
© 2010 Duncan Double