storm duties…

Posted on Thursday 26 February 2015

Georgia Morning

A few years back, I made an attribution error [Adolf Meyer [1866-1950]…]. I credited Adolf Meyer, the influential early American Psychiatrist with the bio·psycho·social model. It was an easy error to make. Meyer’s model was psycho·biology and Meyer’s wife was a major founding figure in American Social Work. But looking back, it highlights how sometimes big things are happening all around you, but you’re too caught up in your own scene to see them:

George Engel [1913-1999] & Adolf Meyer [1866-1950]

The bio·psycho·social model was actually proposed by George Engel in 1977 in an article in Science – Mea Culpa:
by George L. Engel
Science. 1977 196[4286]:129-136.
The article opened with:
At a recent conference on psychiatric education, many psychiatrists seemed lo be saying to medicine, "Please take us back and we will never again deviate from the ‘medical model.’" For, as one critical psychiatrist put it, "Psychiatry has become a hodgepodge of unscientific opinions, assorted philosophies and ‘schools of thought,’ mixed metaphors, role diffusion, propaganda, and politicking for ‘mental health’ and other esoteric goals". In contrast, the rest of medicine appears neat and tidy. It has a firm base in the biological sciences, enormous technologic resources at its command, and a record of astonishing achievement in elucidating mechanisms of disease and devising new treatments. It would seem that psychiatry would do well to emulate its sister medical disciplines by finally embracing once and for all the medical model of disease.

But I do not accept such a premise. Rather, I contend that all medicine is in crisis and, further, that medicine’s crisis derives from the same basic fault as psychiatry’s, namely, adherence to a model of disease no longer adequate for the scientific tasks and social responsibilities of either medicine or psychiatry. The importance of how physicians conceptualize disease derives from how such concepts determine what are considered the proper boundaries of professional responsibility and how they influence attitudes toward and behavior with patients. Psychiatry’s crisis revolves around the question of whether the categories of human distress with which it is concerned are properly considered "disease" as currently conceptualized and whether exercise of the traditional authority of the physician is appropriate for their helping functions. Medicine’s crisis stems from the logical inference that since "disease" is defined in terms of somatic parameters, physicians need not be concerned with psychosocial issues which lie outside medicine’s responsibility and authority…
and ended with:
I hope the example of Mr. Glover, with all of its oversimplification, indicates how the working conceptual model used by the physician can influence the approach to patient care. The biopsychosociaJ model is a scientific model. So, too, was the biomedical model. But as Fabrega pointed out, by now it has become transformed into a folk model, actually the dominant folk model of the Western world. As such it has come to constitute a dogma. The hallmark of a scientific model is that it provides a framework within which the scientific method may be applied. The value of a scientific model is measured not by whether it is right or wrong but by how useful it is. It is modified or dis- carded when it no longer helps to generate and test new knowledge. Dogmas, in contrast, maintain their influence through authority and tradition. They resist change and hence tend to promote opposition and the promulgation of rival dogmas by dissident figures. The counter dogmas being put forth these days in opposi- tion to biomedical dogma are called "holistic" and "humanistic" medicine. They qualify as dogmas to the extent that they eschew the scientific method and lean instead on faith and belief systems handed down from remote and obscure or charismatic authority figures. They tend to place science and humanism in opposition. But as the history of the biomedical model itself has shown, progress is made only where the scientific method is applied. The triumphs of the biomedical model all have been in the areas for which the model has provided a suitable framework for scientific study. The biopsychosocial model extends that framework to heretofore neglected areas.
It was followed by this next article which was presented at the 1979 APA Convention and published in the American Journal of Psychiatry in the same month in 1980 that the DSM-III was presented and adopted at the APA Convention:
American Journal of Psychiatry. 1980 137[5]:535-544.

Engel was actually a figure in my own life back in the day. I was an internist who had discovered that practicing medicine wasn’t quite like it had been in training. Following the patients from beginning to end, I quickly realized that there was more to doctoring than the science of disease I had learned, because the persona and the life of the patient had so much more to do with the treatment of patients than was apparent in the environment where I trained. I had learned about disease from the knowledge gained from groups united by diagnosis, but practicing medicine was with one patient at a time, and the one part was a lot bigger factor than I might have ever imagined. Engel was an internist who had become a major figure in psychiatry and psychosomatics. I had read his work and considered applying to psychiatry in Rochester where he was because he was there when I decided to add psychiatry to my skillset. But after spending three years in Europe as a soldier, I think I was ready to come home, and ended up in Atlanta where, unlike Rochester, today’s snow is considered a blizzard [‘southern born and southern bred‘ as they say]. I finished my psychiatry residency in 1977 and by 1979 & 1980, I was directing a residency, in Analytic training, and way too busy to know about the coming storm. I went to neither APA Convention [1979, 1980]. The young faculty like me stayed at home and kept the home fires burning.

So when Dr. Carroll said in his comment yesterday, "… we can agree about the historical failure consistently to implement the biopsychosocial model in the care of patients with schizophrenia", he wasn’t kidding. I really didn’t know that Engel had introduced that model during and as part of the controversies that swirled around in those days when the DSM-III was in the works. Thinking about it now, from my perspective I’m not sure it was consistently or fully implemented anywhere – period.

Southern storm duties call me right now. Wood for the fire, etc. But I think it’s a good place for me to take a breather and gather my thoughts. In the meantime, I refer you to the debate that went on in the comment section of my post which side of the street?…. It’s well worth the read both for content and how such exchanges should be conducted – respectfully…

I call it "winter park benches with chiminea"

    February 26, 2015 | 9:19 PM

    Nice education to the introduction of the biopsychosocial model. Shame it died when the extremist biological faction found the purse strings…

    No real profit margin to providing care, thanks to the role of the real basis to biology, that being business!

    What does Marley say to Scrooge, “mankind should be our business!”

    Yeah, how many doctors can say that with a straight face these days?!

    February 26, 2015 | 10:44 PM

    nice digs old man.

    you earned them of course, but nice digs.

    James O'Brien, M.D.
    February 27, 2015 | 12:03 PM

    There’s no money is “psycho” or “social”. There’s also more guilt and responsibility and work in “psycho” or “social”. Bio trampled the other two because that’s where the money was and parents and patients didn’t have to feel bad. Bio was the perfect Rx for a narcissistic quick fix culture. Notice that very few people talk about personality disorders or Axis 4 anymore. When I was in training in the eighties, we always talked about personality structure and ego weakness. And Anna Freud’s hierarchies of defense mechanisms. If we got paid for Axes 2 and 4 we would talk about it. No major mystery here. Basic B.F. Skinner reward psychology and psychiatrists are not above this.

    James O'Brien, M.D.
    February 27, 2015 | 12:07 PM

    BTW note the delicious irony. “Psychosocial” explains the triumph of bio but “bio” does not!

    February 27, 2015 | 5:02 PM

    Managed care played a sizeable role in eliminating Axis 2 and 4, and how pathetic so many in psychiatry let that path to a pit be labeled as appropriate!

    Treatment resistant illnesses, yeah, if clinicians started looking at comorbid Axis 2 as factors to struggles, then could the patient have an altered ITP that could, are you sitting down readers(!), have an impact in improving treatment outcomes?!

    But, as Dr O wisely points out, no reimbursement for Axes 2 & 4 as etiologies to illness. Follow the money, find the culprit!

    James O'Brien, M.D.
    February 27, 2015 | 5:53 PM

    Absolutely. I remember the time in the eighties working in the hospital when the administrators began demanding that psychiatrists stop using Axis 2 disorders and conduct disorders in adolescents.

    We all know from practice that 90+ of people’s problems are Axis 2 traits (broadly defined) crashing into Axis 4. But there are no more CME lectures on this anymore. I was fortunate enough to be a resident where we did talk about this all the time. These are problems that need to be talked through, and not, in Dr. Carroll’s erudite words, allostatic collapses.

    Instead we know have entities like “forme fruste” biploar illnesses for what we used to call Cluster B personality traits. The thing is if you have these traits these are things you need to work on. As someone who has benefitted from psychodynamic therapy, I am opposed to anything that subtracts from or excuses an effort at honest self-examination and the benefit of increased psychological resiliency.

    berit bryn jensen
    February 28, 2015 | 7:32 AM

    The other day, in calmer weather, winds at more normal (usual) speeds, I went to collect the bundle of books I’d ordered at the sales. No DSM or ICD, thank you, but a thick volume named “Den nye nordiske floraen”, written and illustrated beautifully by Swedes emminent in the profession and art of botany. It’s comparable to the DSM5 in size and cost, but exquisite and at a discount, as the field of botany may have evolved in ten years since first printing, though the plants probably have changed little.
    Taraxacum is the family I happened upon when I opened the book at ramdom. To my huge surprise, there are 13 pages of known varieties of this common, hardy plant, just for the Nordic countries, drawings and maps, one variety said to be very rare, found only in the mountains of Dovre, and only at a few places with lime in the ground.
    Changes in botanical taxonomy do not disturb plants, but may disturb devoted botanists eager to advance science and their place in it. With us humans it’s a different story, rife with catastrophic evils, historically and to this day.
    I learn a lot from dr Nardo’s blog, as I hope more psy-professionals also do. Scientific attitude is (should be) one of generosity, honesty, humility, hard, painstakingly meticulous work and patience, I think.

    berit bryn jensen
    February 28, 2015 | 8:10 AM

    Very interesting article by George L Engel! Thank you!

    For people fair socio-economic conditions are as fundamental as lime to plants. . Starved of livelyhood even the hardiest shall shrivel, wither and die, living conditions too harsh… We are in dire need of people, professionals and politicians to cooperate and wage peace and justice. The rest is vanity…

    James O'Brien, M.D.
    February 28, 2015 | 8:11 PM

    Poverty doesn’t explain schizophrenia…it can explain poor treatment for it but it is not related to the genesis of the illness

    berit bryn jensen
    March 1, 2015 | 5:36 AM

    Since no expert can answer the question of what schizophrenia is and why, and validity and reliability of the diagnosis is unimpressive, I consider it a safe guess that poverty is one of many negative factors increasing risks and setting the stage for more adversity, and worse outcomes, re Richard Wagner among many…

    March 1, 2015 | 2:22 PM

    I think many illnesses, psychiatric and somatic, are biopsychosocial in origins, and even if schizophrenia is biologic from a mostly biological perspective, the choices patients make psychologically and socially inevitably exacerbate the illness further without effective, persistent interventions.

    Who knows as the patient regresses personally, socially, psychologically and risks being more impoverished because of the asocial tendencies of the illness that loss of access to usual lifestyle choices only aggravates the illness further to a point of being entrenched. Nature and nurture only differ by a couple of letters alone.

    Even a somatic illness like Multiple Sclerosis is not going to be managed by meds alone. And how many patients these days are just reflexively put on antihypertensive meds alone on day one of presenting with high blood pressure? Yeah, I have plenty of patients talking about diet, exercise, management of stress, and a need to step back and reexamine life style choices in general to manage their cardiovascular health…

    This quick fix mantra pervades in almost all of health care until proven otherwise. And as the mantra relies on, hear the lie enough….

    March 1, 2015 | 4:05 PM

    Hmm, on cue comes this, while not from a source I really like to credit for reliable information, I still see it as a random chance moment:

    in there was this: “In Alberta, Bonnie and others have tried for years to get the provincial health care system to put micronutrient formulas on the ‘formulary list,’ which would enable doctors to prescribe them for mental health and people to obtain them at no (or little) cost. To the best of our knowledge, there is no insurance system in the U.S. that will cover the cost of a nutrient formula for mental health (there are some individual nutrients such as folic acid that are covered for heart health). What we need is for people to be able to afford better food and nutrient supplements as needed.”

    I am sure this is not new information to many readers, but, it comes up now, so I will note it as part of my point that illness is multidimensional. But, the powers that be don’t want that information out there, diminishes the sales of Big Pharma.

    Unfortunately, can the schizophrenic patients afford products to improve their nutritional states? We know that answer for the most part, true?

    berit bryn jensen
    March 2, 2015 | 8:11 AM

    “Schizophrenic pasients” are human beings categorized, labelled, stigmatized and treated as unworthy others by psychiatrists invested with monopolizing power. The construct was – as everyone should know – invented for the purposes of ambitious men, to crank up and hide uncertainty within a scientificsounding paradigm.

    Schizophrenia is an abstract diagnosis that has created professional identities, industrial riches, served political interests and left countless of its pawns with iatrogenic injury, crippled lives and early death. Since its invention by Bleuler, building on Kraepelin, millions of unfortunate humans have had to suffer the consequences of this quasi-science rooted in ambition, illusions, colonizing business interests and politics, fuelled early on by generous grants from the Rockefeller institute to prominent research facilities in Germany and America before WWII…

    We need a paradigm of empathy, human rights, justice. “Schizophrenic patients” is a delusion spread by psychiatry, infecting how they and western societies see, think and speak about persons they prefer to see as objects instead of fellow brothers and sisters. Quakers got it, long ago.

    Naturally, nutritious food is helpfull. So would openminded humility, faced with great unknowns, but much known about alliviating suffering not being done, and human rights abuses committed to this day, while researchers prefer to look for fame and fortune by searching biological faults/genetic aberrations – as though nothing is learnt from history, neverending modernity, continually worshipping golden calves…

    James O'Brien, M.D.
    March 2, 2015 | 2:36 PM

    Looks like that poor fella who died on the streets of Skid Row, who unwisely went for a cop’s gun, and released from the mental health care system, may have died under the influence an “abstract diagnosis”. Or, more likely than not, he did have a very real mental disorder.

    Can we please stop with the false dichotomy that there are either 300 mental disorders according to DSM that include all of life’s slings and arrows or no diagnoses because there is no biological markers?

    Feighner basically had it right when he stated that scientific taxonomy had it down to about 14-15 legitimate mental disorders.

    Somehow human beings were able to describe the difference between a dog and cat even before animal DNA testing existed. Based on observation and description of groups of traits.

    berit bryn jensen
    March 2, 2015 | 5:25 PM

    Dogs and cats are different species. Sisters and brothers are the same species, regardless of psy-diagnosis on account of differing behaviors and valueladen labels from more or less predjudiced men.

    We cannot know if biological markers of mental suffering ever become documented facts. But we can know from experience and history that psychiatric researchers are in dangerous waters in the quest for genetic evidence of abstract scientificsounding diagnosis, so easily hijacked by prejudice, selfinterest, professional, economic, political power. Living in western, developed nations predict worse outcomes for patients labelled with the abstract diagnosis schizophrenia than those in poorer, less developed … found by WHO, long ago, discarded by the mainstream, just as the better results of caring Quakers, Loren Mosher, Jaakko Seikkula, Carina Håkonsson… Biological psychiatry, the medical paradigm, is a monumental failure for patients, families, society. There will be change, I think, I hope.

    James O'Brien, M.D.
    March 2, 2015 | 6:54 PM

    German Shepherds and Pugs are the same species but somehow we are able to describe the difference. To use Dr. Carroll’s example of Parkinson’s, it’s not just someone’s alternative way of getting around.

Sorry, the comment form is closed at this time.