Psychiatry Reborn is an important and timely book, tackling a subject that has increasingly preoccupied psychiatry and philosophy of psychiatry over the last two decades. The central problem is identified succinctly in the first line of the introductory chapter by J. Pierre Loebel and Julian Savulescu: “Psychiatry suffers from a lack of a unifying theory.” Psychiatry, in the absence of a guiding scientific framework, is operating in a theoretical vacuum. This edited volume, a response to this theoretical vacuum, is concerned with two broad themes. The first strand is a philosophical and scientific line of inquiry that has to do with the complex ways in which the biological, psychological, and social realms interact with each other. Although no unifying theory is offered – the science isn’t there yet unfortunately – we are offered glimpses of what aspects of such a unifying theory may look like. 

The second theme has to do specifically with the “biopsychosocial model” (BPSM), and there is much discussion of what the model – if it is a “model” at all, which many authors in the book doubt – consists of and what it asserts. For those working in psychiatry, the BPSM is so pervasive and yet so intangible that many attempts to define BPSM tend to generate a state of confusion akin to that of the fish asking, “What the hell is water?” in David Foster Wallace’s parable.

The skeleton of the book consists of three Loebel lectures (and associated workshops) that were held in Oxford from 2014 to 2016, with the three lecturers being Kenneth Kendler (2014), Steven Hyman (2015), and Essi Viding (2016). The project was funded by Pierre and Felice Loebel, and Pierre Loebel also serves as consulting editor for this volume. The three lectures have been adapted as book chapters, with accompanying commentaries as well as independent essays which broadly fit with the larger theme. The chapter by Kendler (co-authored with Christopher Gyngell) relates to multilevel interactions in psychiatric conditions, particularly how genetic factors interact with environmental and sociocultural factors in bottom-up and top-down causality, and how the causal risk factors for psychiatric disorders are “dappled” across multiple levels of explanation. The chapter by Essi Viding relates to combining multiple levels of analysis to improve understanding of developmental risk and resilience. The chapter by Hyman (co-authored with Doug McConnell) discusses the relationship between, and the incommensurability of, folk psychological and neuroscientific explanations of mental illness.

The three lectures reside firmly within the first theme of the book, the complex relationships between phenomena at multiple levels of explanations in psychopathology. Some of the other chapters tackle the BPSM more directly, and these include chapters written by Rebecca Roache, Walter Sinnott-Armstrong and Jesse Summers, S. Nassir Ghaemi, and Doug McConnell. The problem with BPSM is expressed pithily by Sinnott-Armstrong and Summers: “it wavers between the obvious and the implausible” (page 96). Anything that the BPSM has to say about causes and treatments of mental illness seemingly has to be diluted to the point of triviality or otherwise it becomes indefensible. 

Before I discuss the BPSM in more detail, I have to say that some of my favorite chapters from this book do not fit easily within the two broad themes of multi-level interactions and the BPSM.  Rachel Cooper (“When answers are hard to find, change the question: Asking different causal questions can enable progress”) argues that in order to make scientific progress, sometimes we need to ask different causal questions, and suggests what these causal questions may look like in psychiatry. Neil Levy (“The truth in social construction”) argues elegantly that classifications such as RDoC need to take social construction of mental illness into account in order to be successful. Tim Thornton (“Psychiatry’s inchoate wish for a paradigm shift and the biopsychosocial model of mental illness”) examines what it would really mean for psychiatry to undergo a paradigm shift and whether it makes sense for us to desire such a change. Doug McConnell (“The proper place of subjectivity, meaning, and folk psychology in psychiatry”), in his commentary on Hyman’s lecture, defends the essential role of folk psychological explanations in psychiatry. These somewhat quirky chapters are the best part of the book, where the creativity and vitality of ideas really shines through.

Ok, back to the BPSM. After considerable discussion, Rebecca Roache arrives at the following conclusions regarding the BPSM (pages 377-378): 

• “commitment to the biopsychosocial model should not involve an a priori acceptance of the view that mental illness always has biological, psychological, and social causes.” 
• “our understanding of any given mental illness may best be advanced by considering explanations at each of the biological, psychological, and social levels”
• “Commitment to a biopsychosocial approach should not involve commitment to the view that treatment of mental illness should always involve interventions at every level. Which treatment is most effective in any given case— that is, whether a biological, a psychological, or a social approach— can best be decided empirically.” 

McConnell, summarizing the arguments by Sinnott-Armstrong and Summers, writes: “At the very minimum, the BPS model is making two weak disjunctive claims: mental disorders are caused by biological, or psychological, or social factors, or some combination of them; and mental disorders will be most effectively treated by biological, or psychological, or social treatments, or some combination of them. However, the BPS model might also make stronger conjunctive claims: mental disorders are always caused by a combination of biological, psychological, and social factors; and mental disorders will always be most effectively treated by a combination of biological, psychological, and social treatments.” (page 381).

McConnell goes on to discuss that the conjunctive claims are not true a priori but can be weakened to suggest that the causes and treatments of mental disorders will typically require a combination of causes and treatments. Sinnott-Armstrong and Summer argue that it would be inaccurate for BPSM to claim that mental disorders are constituted by combinations of biological, psychological, and social characteristics. They show that mental disorders, as currently understood, are constituted by psychological aspects (i.e. in the absence of psychological features characteristic of mental disorder, we would not call something a mental disorder purely on biological or social grounds). McConnell also proposes that BPSM integrates scientific approaches with humanistic approaches, making room for both mechanism and meaning: “This thoroughgoing pluralism does not just resist bioreductive approaches to psychiatry but scientific reductionism more broadly.” (page 382)

In recent months I have had the opportunity to revisit George Engel’s original writings and, as always, I am struck by the disconnect between Engel’s views and what is taken for granted to be BPSM by most commentators. Engel’s voice is remarkably fresh and relevant, despite the passage of time. I imagine that George Engel – widely credited as the person who proposed the BPSM – would have been astonished at, if not flabbergasted with, all the disjunctive, conjunctive, and constitutive claims that supposedly represent the BPSM. These claims relate to popular understanding and misunderstanding of the BPSM but are prominently missing in Engel’s writing and have little to do with the BPSM that he envisioned. I have written elsewhere and also elaborate in a forthcoming article (“From Engel to Enactivism: Contextualizing the Biopsychosocial Model”, co-written with Kristopher Nielsen) that Engel was less concerned with questions of causation, and more concerned with our notions of health and disease, and psychosocial influences in the form of illness interpretation and presentation, sick role, seeking or rejection of care, the doctor-patient therapeutic relationship, and role of personality factors and family relationships in recovery from illness, etc. Engel wanted to bring the human domain within the realm of medical and scientific inquiry. This leads me to think that the most important voice missing from this volume on biopsychosocial psychiatry is that of Engel himself! Fortunately, this is an oversight easily rectified: readers are highly encouraged to pair this volume with Engel’s seminal articles, particularly his 1977 article in Science and the 1980 article in the American Journal of Psychiatry.

In some ways the book was already dated before it was even published, though by no fault of its own. This is because of two important scholarly developments relating to the BPSM and bio-psycho-social causal interactions that happened in between 2017 and 2020: Derek Bolton and Grant Gillett’s book The Biopsychosocial Model of Health and Disease: New Philosophical and Scientific Developments (2019) and Sanneke de Haan’s book Enactive Psychiatry (2020; reviewed for Metapsychology Online Reviews by me here). Bolton and Gillett reconceptualize the BPSM as a philosophical and scientific account of bio-psycho-social causal interactions, beginning with an account of causal interactions in biological systems that cannot be reduced to physics and chemistry, while de Haan offers the philosophy of enactivism as a solution to the integration problem in psychiatry. Both are remarkable efforts and their influence on the scholarship in this area has already been tremendous. For that reason, their absence in this volume stands out prominently. 

Psychiatry Reborn is a serious and scholarly attempt at making sense of the fractured nature of psychiatry as a discipline. It does so by engaging with philosophical arguments as well as research studies, and it is a valuable book for psychiatrists, psychologists, and philosophers. It is particularly essential reading for students of the BPSM and pluralism in psychiatry, and will shape the discussion on how to best understand the BPSM for years to come.

Awais Aftab, MD, is a psychiatrist in Cleveland, OH, and clinical assistant professor of psychiatry at Case Western Reserve University. He leads the interview series “Conversations in Critical Psychiatry” for Psychiatric Times.

Categories: Philosophical, Psychiatry

Keywords: biopsychosocial