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Taking stock of the biopsychosocial model in the field of 'mental health care'.

This paper will review the legacy of the bio-psychosocial model in the field of 'mental health care'. The latter, placed in speech marks because it is typically more about responding to presumed mental disorder than promoting mental health, can be found in a range of professionals. This range is often now called the 'psy complex'-: psychiatry, clinical psychology, psychiatric nursing, mental health social work, counselling and psychological therapy. It is relevant to note at the outset that this list describes occupational groupings that nestle together regularly in those work contexts, which assess and treat people with mental health problems. Their core socialisation in higher education is predicated on a range of academic disciplines from the biological and social sciences.

With these preliminary comments in mind about the ambiguities of the 'psy complex' and 'mental health care', we now appraise an important tension, between bio-determinists and their critics that emerged at the turn of the 20th century and which remained unresolved a century later (Clare, 1999, cf .Guze, 1989).

The biomedical and bio-psychosocial models

The bio-pychosocial model was announced formally by George Engel in the final quarter of the 20th century (Engel, 1977). A physician with psychoanalytical training (not a psychiatrist), Engel had a longstanding interest in the psycho-somatic interface and the meanings that patients attached to their illness experience. By that time, Engel could draw confidently upon General Systems Theory (GST), as a theoretical rationale.

GST was developed by the biologist-turned-philosopher Ludwig von Bertalanffy as the 'organismic system theory' before the Second World War (von Bertalanffy, 1932, 1951). It went on to promise a generic basis for holistic paradigms in a range of scientific disciplines. GST arose in part because of the unresolved tension, within biological science, between old style vitalism and the new mechanistic orthodoxy in science at the turn of the 20th century. The strictures of GST went on to demand disciplinary humility, as impermeable disciplinary boundaries form blinkers to full understanding and so risk creating misleading forms of reductionism. GST instead invited inter-disciplinary respect and even the tentative prospect of a trans-disciplinary body of knowledge.

Given that the focus of this paper inter alia is about a recurrent critique, in the field of mental health, of crude and axiomatic biodeterminism, it is pertinent to note the biological roots of GST. It was developed fully by von Bertalanffy in the wake of Viennese coffee shop discussions with the experimental biologist Paul Weiss. Both rejected the logical positivism of the Vienna Circle of the time. Weiss had reported that the mechanistic predictions of laboratory biological science failed, in the fluctuating uncertainties outside, six years earlier than von Bertalanffy's first main paper on systems theory (Weiss, 1926). (Note this claim was about biology not the legitimate predictive confidence of physics.)

A seminal implication of this predictive failure of laboratory-based studies was that biological and supra-biological knowledge claims needed to reflect open, not just closed, systems. This required sensitivity to: levels of organisation in systems; emergent properties at each level; and inter-connectivity and unpredictability. This was a powerful counterbalance to reductionism within uni-disciplinary bodies of knowledge and a caution against over-certain generalisations, when and if open systems were evident. In the case of the focus of this paper, matters to do with the mind or human conduct ipso facto will always be aspects of open not closed systems (Bateson, 1972).

A potential advantage of GST is that it has the conceptual infrastructure to avoid reductionism and deal with goals, values and meanings, as the latter are describable forms of information in systems. However, GST can still be used in a narrow way by investigators who punctuate reality for their own convenience and only offer its mechanistic insights without reference to values and goals (Wilden, 1980). But these arguments about the radical and conservative uses of GST were to be found in the mid-20th century. A century earlier psychiatry had emerged in a state of ignorant bliss.

The professional project of psychiatry

The aspirations of physicians, to account in a pre-eminent manner for mental abnormality, date back to the mid-19th century, when the term 'psychiatry' first appeared. What now, usually disparagingly by critics, tends to be called 'the medical model' or 'the bio-medical model' is traceable to that period, when the overwhelming focus was on lunacy, rather than the wide range of 'mental disorders' under the jurisdiction of psychiatry today. Asylum psychiatry was co-constituted by three mutually supportive strands of professional advancement. The first was the need to establish an administrative monopoly over madness. In the wake of the Regulation of Madhouses Act 1777, there was clearly a humanitarian case to reform the poor conditions' extent in workhouses and prisons affecting lunatics.

In the early Victorian period this reforming zeal was championed by lay administrators who offered the early version of moral treatment (Digby, 1985) but by the middle of the 19th century, their governing role was displaced by medical superintendents (Scull, 1979). In the early Victorian period many lunatics remained incarcerated in workhouses and prisons, indeed proportionately their numbers actually increased in the workhouse system leading to the Report of the Metropolitan Commissioners in Lunacy in 1844 to reinforce the need for the transfer of them to asylums- a shift further encouraged by the Lunacy Act of 1862 (Donnelly, 1983).

The second strand in the professionalisation of psychiatry was to establish that madness was biologically caused (with assertion rather than evidence if necessary). Even though accounts of reasons for admission to hospital during the mid-Victorian era included many moral (now psychological), not just physical, explanations (Hunter and Macalpine, 1963) biological reductionism soon became an important plank of medical authority. The close interweaving of these first two strands was evident in this period. The medical hegemony they created, with its hoped-for-biological-reductionism and manoeuvring for an administrative monopoly, were captured succinctly by this editorial from the Journal of Mental Science (now the British Journal of Psychiatry) in 1858:
 Insanity is purely a disease of the brain. The physician is the
 guardian of the lunatic and must ever remain so.... (cited in
 Scull, 1979)


The third historical strand to contextualise the nature of 'the medical model' is the norm of eugenics at the turn of the 20th century. Eugenics was championed not only by asylum psychiatrists but also by the pre-genitors of British clinical psychology- the academic culture at University College London, which created 'biometrics', now called 'psychometrics' or 'the psychology of individual differences'. This began with the work of Francis Galton, Karl Pearson and Charles Spearman, who developed the confident infrastructure of modern behavioural statistics (Pilgrim, 2008). It was kept alive through generations of metropolitan psychologists in the work of Cyril Burt and then one of the main founders of British clinical psychology Hans Eysenck. Galtonian biometrics in England and German psychopathology, to be discussed now, expressed a eugenic consensus about mental abnormality, which still has resonances in the 'psy complex' today (Pilgrim, 2008). These protopsychologists in the first half of the 20th century were bio reductionists and positivists, so they offered a view consistent with biological psychiatry.

With these interweaving three strands in mind, somatic reductionism represented the triumph of medical science at the turn of the 20th century. This was typified by the work of Emil Kraepelin (1883). His position, which found popular support in his psychiatric colleagues, who were exercising their newly established medical authority over madness, could be summarised in three axioms:

1. Mental disorders are congenital

2. Mental disorders are separate, naturally occurring, categories

3. Mental disorders are fixed and deteriorating conditions

Kraepelin depicted abnormal states in the way a geologist or botanist would classify rocks or plants. But this was not just about classification ('psychiatric nosology') it was also about an axiomatic position about the nature of psychiatric knowledge. It began a tradition of medical naturalism in the profession, which remains evident today. Kraepelin believed (and his current sympathetic followers still believe) that a psychiatric diagnosis is a nonproblematic fact, because it is a direct read-out of external reality (Hoff, 1995). So, for example, a 'schizophrenic' is a visible embodied manifestation of an objectively describable disease entity called 'schizophrenia'.

A counter-Kraepelinian time line

By 1914 asylum psychiatry had a self-satisfied belief in progress arising from the mixture of the natural scientific method and eugenics (Doerner, 1981). The profession had little interest in mental health problems other than madness and practitioners developed their status via the control of beds in the asylums. This emphasis on the management of sequestrated madness, arising from the assumed tainted gene pool of the underclass, looked set fair to define what we now call 'mental health care'. However, that closed system approach was not sustainable in the light of the First World War.

Shellshock

The cataclysmic 'Great War' created the conditions of possibility for other forms of medical psychology. The officers and gentlemen and working class volunteers breaking down in the trenches, with predictable regularity, were, after all, 'England's finest blood' (Stone, 1985). To impose a biogenetic explanation for their mental weakness was tantamount to treason. This stalling of the professional project of eugenic asylum psychiatry in civil society during peacetime, because of its poor fit for wartime conditions, created a space for alternatives to emerge.

Psychoanalysis

Although Freud had made his position clear over a 20 year period, his medical colleagues still largely dismissed him as an irrelevant crank prior to the First World War. Just before its outbreak a presentation of Freudian ideas to the Neurological Section of the British Medical Association by Eder and Jones saw the audience walking out en masse (Stone, 1985). But by 1919 the first section of the British Psychological Society, the Medical Section, was formed, swelled by the returning shellshock doctors. In the same year, the British Psychoanalytical Society was fully launched, after a failed false start in 1913. A year later the Tavistock Clinic was established. Suddenly the character of psychiatry was changing- or at least for a while.

Laboratory behaviourism

In Russia, Pavlov could demonstrate, with ease, how to make an animal miserable or even catatonic by manipulating stimuli in the laboratory under conditions they could not escape (Pavlov, 1941). In the USA, Watson and Rayner (1920) could demonstrate how to make an innocent child artificially fearful in the laboratory. . Pavlov's cruel experiments (they would probably fail modern research ethics committee scrutiny) offered evidence that pre-figured the later environmentalist descriptions of the genesis of depression-what Seligman (1975) called 'learned helplessness'. They also prefigured the notion of 'entrapment', used by psychiatric researchers to account for both psychosis and depression (Bateson et al 1956; Brown et al, 1995). Indeed Pavlov's own description of the dogs' behaviour was in relation to 'schizophrenia' not 'depression'.

Thus, when faced with an intolerable situation, with no escape, any mammal can become distressed, confused, confusing and dysfunctional. Any of us can be rendered crazy and miserable by circumstances, when past vulnerabilities and current inescapable contingencies coalesce. These demonstrations of 'experimental neurosis', by shiny-new, laboratory-based, behaviourism provided evidence of both environmental determinism and entrapment. But the latter was for others to extrapolate later. Ironically, these laboratory behaviourists were also reproducing the error of closed system reasoning, which was presently to be exposed by Weiss and von Bertalanffy.

Adolf Meyer and the beginnings of social psychiatry

The Swiss emigre Adolf Meyer, a psychiatrist who spent most of his working career in the USA, was to influence a range of Anglo-American academic psychiatrists in developing a bio-psychosocial model in their profession (e.g. Henderson and Gillespie, 1927). He began to re-capture some of the administrative insights of the admission records of the past, about personal circumstances of patients, which Kraepelinian psychiatry now insistently discounted.

Meyer by no means ignored biology nor did he reject diagnosis but he argued that each patient needed to be understood uniquely (Meyer, 1952; Pilgrim, 2002; Double, 1990). He suggested that clinicians should be interested in why this patient is presenting with these problems at this time in his or her life. For Meyer, it was not simply a matter, as it was for Kraepelin, of forcing a patient, Procrustean-style, into a pre-existing category. Instead he argued that individuals have historically derived psychological tendencies. These then encounter particular biographical contexts for good or ill. It can be seen then how Meyer's views anticipated and were compatible with GST.

Evidence for the social causes of mental health problems

These social-environmentalist objections to crude bio-determinism, from psychoanalysis, behaviourism and Meyer's 'psychobiology', were joined by other evidence amassed in the mid 20th century .

* Despite Kraepelin's pessimistic axiom about the fixed and deteriorating nature of mental disorders, it soon became evident that around a quarter of those with a diagnosis of 'schizophrenia' recovered (Hinsie, 1931). Later social psychiatrists were to demonstrate that recovery varied with the socio-economic context involved (Warner, 1985). It seemed then that rather than being on genetically-set tramlines, madness might be inflected by its social context.

* The Wall Street crash demonstrated that sudden changes in social conditions could have immediate implications for the mental health of the population (Dohrenwend, 1998). As with the example given earlier, of the shellshock problem and 'England's finest blood', it was clear that environmental contingencies could be central to our attempts to understand mental health problems.

* When the labour and extermination camps were liberated at the end of the Nazi holocaust, dramatic environmentalist insights were provided for psychiatry. Skeletal figures, barely alive, paced up and down stereotypically and refused to move from their huts to new clean accommodation. The apparently strange behaviour of chronically hospitalised psychiatric patients then began to make sense as 'institutional neurosis' (Barton, 1958) or 'institutionalism' (Brown and Wing, 1962). (Barton was a Red Cross observer of the camp openings, as a medical student.)

* Attachment theory emerged, as a link between psychoanalysis, behaviourism and ethology. The work of John Bowlby and his colleagues formed a bridge between apparently competing styles of psychology to reinforce the message about the interaction of past and present environmental determinants of mental health problems (Pilgrim, et al. 2009).

Although environmentalist approaches to mental health work peaked during war time, between the wars it was business as usual for Kraepelinian psychiatry. For example, being temporarily out of favour, no asylum doctors were invited to sit on the Royal Commission of 1926 (the MacMillan Review) examining services and law related to lunacy in England. But by the 1930s, the Kraepelinian view was re-established, by asylum psychiatry; categorical labelling and somatic treatments once more dominated clinical routines. By 1950 the tension between military and asylum psychiatry was to lead to a range of new ways of examining mental health problems.

Contestation after the Second World War

During the 1950s, there was the breathlessly announced 'pharmacological revolution', with minor and major tranquillisers centre stage. On the other hand, the critics of psychiatry were forming a disjointed queue. There was no obvious co-ordinated critique; no international conspiracy to wreck the hegemony of the biomedical approach to assessment and treatment (cf. Hamilton, 1973; Roth, 1973; Wing, 1978). Instead that hegemony encountered resistance from separate quarters.

In this post-war period, many of the bio-psychosocial resonances of Meyerian psychiatry were embraced and expressed by 'social psychiatry'; an inter-disciplinary project, which included psychiatrists, psychologists and sociologists (Pilgrim and Rogers, 2005a; Cook and Wright, 1995; Goldberg and Huxley, 1992; Falloon and Fadden, 1993). For social psychiatry, the legacy of Meyer meant that diagnosis was dealt with en route to understanding the link between mental states and social contexts (Lawson, 1989). Despite its demoted role, diagnosis was not however rejected, which was to make social psychiatry vulnerable to more radical critiques of psychiatric theory and practice. Also philosophical realism itself came under attack within social science, particularly from French post-structuralism (see later), which joined, and to some extent challenged, the main player in social research about mental health either side of the Second World War: the Chicago School of Sociology.

The 'ecological wing' in Chicago developed a form of social epidemiology which mapped the relationship between class, locality and mental illness (Pilgrim and Rogers, 1994). This was a strong strand within social psychiatry but the latter also took on board elements of the next more subjectively-oriented part of the Chicago School. That other wing was symbolic interactionism, traceable to Cooley (1902) and GH Mead (1934). Here could be find the work of the best known social psychologist-cum-sociologist in the field, Erving Goffman ,on stigma and total institutions (Goffman, 1961, 1963), and the beginnings of labelling theory (Garfinkel, 1956; Becker, 1963; Scheff, 1966; Lemert, 1967).

Within the currents of sociology apparent at the time, the ecological wing was more Durkheimian in orientation (exploring real measurable social forces) (Faris and Dunham, 1939; Srole and Langer, 1962; Hollingshead and Redlich, 1958). By contrast, the symbolic interactionist variant owed more to Weber, via Cooley and Mead, with its emphasis on the exchange of meanings between social actors.

Also radicalised psychoanalysis was to be found in post-war USA, mainly Jewish emigres relocating from Germany- the Frankfurt School (Adorno, et al. 1950; Fromm,1955). This group offered its version of social insights, which incorporated the Freudian and Marxian traditions, about the relationship between inner life and social conditions past and present.

Thus socially-orientated mental health research was inevitably going to reflect the historical lineages of Durkheim, Marx, Freud and Weber and so be variegated in character. By the end of the 20th century, the post-structuralist reaction against the 'grand narratives' these traditions had generated was then added to the mix. It is beyond the scope of this paper to explore the tensions and compromises between these forms of sociological inquiry (see Rogers and Pilgrim, 2005). However, they are noted here to put the role of the bio-psychosocial model into context. It could have been destined to be the only challenger to the hegemony of biological reductionism in psychiatry. But this was not to be- these other forms of social reasoning created new platforms from which to attack orthodox theory and practice in psychiatry and psychology.

One way of contrasting these styles of social understanding with one another and with the versions of naive realism to be found in psychiatry and psychology is to examine their characteristics as bodies of knowledge (in relation to ontology, epistemology, methodology and even political or ethical values). For example, Kraepelinian psychiatry and the psychometrics derived from Galton's eugenics considered that mental characteristics, such as 'general intelligence' or 'schizophrenia', were objective facts and that they were genetically determined. The challenge for science was to measure these characteristics (a focus on quantitative methodology), in order to incrementally build up our objective knowledge of mental abnormality (creating an objectivist epistemology). This knowledge could be used to improve the race or species (a eugenic value system).

By contrast, social psychiatry and its expression in the biopsychosocial model offered an open systems view about ontology (mental illness could be derived from biological, psychological or social forces). It argued that causes and meanings were both important to investigate (it mixed quantitative and qualitative methodologies of epidemiology and ethnography respectively). This generated a mixed body of knowledge (supporting both objectivist and subjectivist epistemologies). This knowledge could be used to reveal the pathogenic psycho-social forces operating in the lives of those developing mental health problems (a value system of scientific humanism).

Current challenges for the bio-psychosocial model

In the light of the above discussion, we can now examine the current standing of the bio-psychosocial model within the psy complex. The following points are pertinent:

* Its advocates can still be found in the large residue of social psychiatry; the progressive interdisciplinary project developed after the Second World War

* That credibility largely resides in the capacity of the model to provide legitimacy for professionals who respect interactionism in its various forms related to: past and present; multiple causes and multiple meanings; and biological, psychological and social causal factors.

* Its advocates reflect a continued commitment to a modernist form of realist epistemology, being oblivious, or hostile, to both the 'postmodern turn' in social science and to the legacy of radicalised psycho-analysis.

However, the above points, summarising the current position of the bio-psychosocial model in the psy complex, also contains some unresolved matters, to which we now turn.

Part of a host of oppositions to the biomedical model

As we noted earlier, just after the Second World War, within Anglophone psychiatry, the bio-psychosocial model, expressed via social psychiatry, was the main challenger to bio-reductionism. It was effectively the only 'progressive' game in town. However, that niche of social sensibility in a psychiatric world dominated by biological reductionism was disrupted by the resonances first of radicalised psychoanalysis in 'anti-psychiatry' and then of 'critical psychiatry' or 'post-psychiatry', under the dominant influence of Michel Foucault (Ingleby, 1980; Miller and Rose, 1986; Parker et al. 1997; Bracken and Thomas, 2006).

The first of these currents demanded a much stronger hermeneutic approach within critiques of psychiatry. The second was anti-realist

Journal of Soc. & Psych. Sci. (2008) Vol.1 (2): 1-39 Pilgrim et al 15 in its orientation, thus shifting the methodological focus from measuring causes and recording meanings to perpetual deconstruction; everything is deemed to be socially constructed and nothing is real or true and so we can do nothing except produce discourses about discourses (Pilgrim, 2000). An indication of the blurred boundaries between these dissenting movements within the psy complex is that although the British Critical Psychiatry Network has contained many who are committed to the Foucauldian view (Bracken, 2003), others remain wedded to realist demands and so they re-state the bio-psychosocial promise of Meyerian psychiatry (Double, 1990; Moncrieff and Crawford, 2001; Moncrieff, 2006).

The coherence and utility of the model

The bio-psychosocial model in psychiatry is an aggregated position of inquiry, implicating a range of sociological, psychological and biological currents of thought. It is an eclectic model or type of syncretism. Its most doubting critics have argued that it is rhetorically social but actually is only interested in the psychosomatic interface in practice (McLaren, 2007).

Despite this sort of fundamental doubt, the optimistic pragmatism of the model to suit the interests of working clinicians who, for whatever motives, resist biological reductionism when explaining mental or physical illnesses cannot be doubted. It is put forward episodically as a laudable holistic rationale for both psychiatry and general medicine and as a useful bridge between psychology and medicine (e.g. Alonso, 2004; McDaniel, 1995; Zimmerman and Tansella, 1996). However, some accounts have emphasised the tendency of medical practitioners, claiming to espouse the model, to focus on the psychosomatic aspects of clinical work, at the expense of social understanding (Dowrick et al, 1996; McClaren, 2007)

The holistic advantages of the model for the management of a range of somatic conditions have now been evinced in relation to amongst others: diabetes (Yamada and Palafox, 2001; Peyrot et al 1999); gestational obesity (Olson, and Strawderman, 2003); low back pain (Truchon, 2001); generalised pain (Kellen,2003); infections (Kiecolt-Glasser et al 2002); rheumatoid arthritis (Covic et al 2003).; the management of pain in AIDS patients (Markus et al. 2000); spinal cord injury (Mathew, et al. 2001); and gastro-intestinal illness (Drossman, 1998).

Given this optimistic and pragmatic inclusive picture for clinical practice, it is important to interrogate the coherence of the model and look sceptically at its inclusive character. Recent advocates of the model place an emphasis on the additive effects of biological, psychological and social factors to account for mental disorders (e.g. Dilts, 2001). In doing so, they evince a mechanistic view of causality without reference to the conceptual validity of psychiatric categories. This has had an implication for clinical psychology not just psychiatry. Many in clinical psychology still adhere to a 'peripheralist' view of psychosis- that it is biologically caused and clinicians can only deal with the fall out. Thus in both professions the 'stress-vulnerability' model is one expression of the bio-psychosocial model, which does not address in a fundamental way the reductionist assumptions of traditional psychiatry. An explicit example of this assumption from clinical psychology was Eyenck's suggestion that the psychoses were biological illnesses to be treated mainly medicinally, whereas the neuroses reflected faulty conditioning and so could be treated by clinical psychologists using behaviour therapy (Eysenck, 1975). A division of labour was being offered to confirm psychiatric assumptions about madness.

An example of the same point is the well-regarded bio-psychosocial model of 'depression' offered by the medical sociologist George Brown and his colleagues (Brown and Harris, 1978; Bifulco and Moran, 1998; Brown et al. 1996). In this work, the possibility of biological vulnerability to depression in individuals is accepted, and it seeks to clarify the past and current interpersonal stressors that increase or decrease the risk of symptom presentation. However, at no point is there any critical non-empirical scrutiny of the conceptual validity of depression and the authoritative role in response from medicine (cf.. Pilgrim and Bentall,1998). Thus the opposition by proponents of the bio-psychosocial model to the bio-reductionism in the mainstream of mental health work does not preclude the unreflective legitimation of Kraepelin's axiom that mental disorders are naturally occurring categories. The ontological status of the latter can go unchallenged.

In addition to the biopsychosocial model being used to account for 'depression', we also find it accounting for 'schizophrenia' (Kotsiubinskii, 2002), 'conduct disorders' (Dodge and Petit, 2003), 'eating disorders' (Ricciardelli and McCabe, 2004; Rogers and Smit, 2000) and 'substance abuse' (Marlatt, 1992). Because of its integrative potential, its use has also been evident at the psycho-somatic interface in relation to post-viral fatigue or 'chronic fatigue syndrome' (Johnson, 1998).

Variants of realism in the academy: we can all recognise a miserable dog

One appeal of the bio-psychosocial model is that it retains a confidence in the reality of mental disorder and in realist knowledge claims about causality. A fear expressed by radical critics of the early constructivist position offered by Szasz (1961), concerning the 'myth of mental illness', was that it would dissuade us from taking the reality of distress and madness seriously (Sedgwick, 1980). Apart from radical constructivists in the field of mental health, most workers producing and using research assume some version of realism. Research is used as a basis for arguing that evidence exists about causes and meanings in relation to the promotion, maintenance and breakdown of mental health. However, these often undeclared or unarticulated assumptions about realist knowledge claims may be more or less critical in orientation.

The distinction between naive and critical realism is made by Bhaskar (1998). He argued that the world and its features really exist. This first proposition is unremarkable to all empiricists and positivists. However, he argues further that the world is structured, differentiated and changing and is investigated by variants of science in constant motion with a variety of goals and supported by a variety of explicit and implicit interests.

Moreover, contra traditional empiricism, Bhaskar argues for the existence of reality beyond what we know empirically and maybe beyond what we will ever know. For him reality exists in an enduring way (it has an intransitive quality) but we generate knowledge about it in ways limited by current methodological competence and with economic, moral and political interests in play, which frame research questions and interpretations of the answers they give (creating a transitive epistemological quality). In the case of mental disorder, the latter transitive state is informed and shaped by the interests of professionals, patients, their relatives and the pharmaceutical industry (Pilgrim, 2007).

Bhaskar also makes the point that the human sciences, compared to the natural sciences, face particular challenges because of their normative and historically-situated character. They require a particular kind of critical and reflective sensibility, over and above that applied to say geology or physics (though they too can be critically scrutinised). That sensibility requires the need for a constant scepticism within human science- a perpetual ideological not just methodological critique of all and any knowledge claims.

This summary of critical realism can be contrasted with naive realism, which separates and discards values and interests from knowledge and assumes that methodological rigour in and of itself ensures bona fide knowledge (scientism). In doing so it assumes simplistically and erroneously that we can observe and measure aspects of reality in a non-problematic way; without reference to the interests and values implied by the pre-empirical and non-empirical constructs that constitute our systems of knowledge. As a consequence, reality and the investigator's knowledge (his or her constructs and observations) are conflated unreflectively. Critical realism draws attention to two types of error, the ontic and the epistemic fallacies, that occur with that conflation:
 In the epistemic fallacy, statements about being are to be
 interpreted as statements about knowledge.... Basically, being
 is understood as perceived being..... In the ontic fallacy,
 knowledge is analyzed as a direct, unmediated relation
 between a subject and being. The ontic fallacy ignores the
 cognitive and social mechanisms by which knowledge is
 produced from antecedent knowledge, leaving an ontology of
 empirical knowledge events (raw perceptions) and a desocialized
 epistemology.... Bhaskar sees a close relation
 between these two fallacies, especially in relation to classical
 empiricism. The epistemic fallacy first projects the external
 world onto a subjective phenomenal map, then the ontic
 fallacy projects the phenomenal entities of that subjective map
 back out on the world as objective sense data, of which we
 have direct perceptual knowledge. So reality independent of
 thought is first subjectified, then the subjectified elements are
 objectified to explain and justify our knowledge. (Irwin,
 1997)


Put simply the ontic fallacy is about naively trusting our immediate perceptions too readily and the epistemic fallacy is about naively assuming that reality is what we call it (in the case of the psy complex 'schizophrenia', 'depression' etc.). As Bateson (1972) noted, the map is not the territory. Both are aspects of reality but both must be studied sceptically. It is in this misleading realm of these mutually compounding fallacies that currently we can identify both the problems of the biomedical model of 'neo-Kraepelinian' psychiatry and the vulnerability of a biopsychosocial model. Moreover, the professionally-centred epistemic fallacy tends to define mental health by its problems rather than by well being in a one-dimensional way. For example, auditory hallucinations are deemed to be pathognomic of a disease entity called 'schizophrenia'. But many people may hallucinate and be quite happy with the experience. It is not self-evident that hearing voices is about a disease entity or that it is always a distressing experience.

Another example of a cul-de-sac for the bio-psychosocial model, because of its continued support for reified natural categories of psychopathology, is the anti-stigma campaign of the Royal College of Psychiatrists. In that campaign rather than stigma being understood primarily as a social process, the profession opted to start at the other end of the telescope by examining the particular ways in which people with specific diagnoses are treated prejudicially. By carving reality at the joints of their own preferred categories, the profession could avoid any critical interrogation of the social history of those categories and the contributory role doctors have themselves in producing and maintaining stigma (Pilgrim and Rogers, 2005b).

Returning to the example given earlier of 'depression', the critical realist position is that the latter is a social construct deployed by Western psychiatry aided and abetted by a range of other interests, including the pharmaceutical industry, which market the magic Journal of Soc. & Psych. Sci. (2008) Vol.1 (2): 1-39 Pilgrim et al 21 bullets of 'anti-depressants'. 'Depression' is a reified concept serving these varied interests.

Having said all of this, we are still able to give reasonable realist accounts of misery, quite legitimately, in a range of social contexts and even for a range of mammalian species, such as Pavlov's poor dogs. Most of us know a miserable dog when we see it or can recall an inner sense of profound anguish and sadness, when faced with the loss of people or control in our lives. As for the emotional consequence of the loss of status, homeland, family, dignity and freedom, the grey-blue skin hue of cold, despondent dockside slaves gave us 'The Blues', as a musical idiom and one way of describing misery.

These are real outer observations and inner experiences. Whilst a range of linguistic forms are used trans-culturally about internal affective states, all human societies past and present seem to have some notion of misery. Thus (contra a radical constructivist account) it is not misery that is socially constructed but our ways of describing and understanding it. Misery may be experienced as an authentic reaction to an existential plight or may be seen as a punishment from God. For the masochist it might be an intense experience to be craved and repeated. These and many other possibilities are closed down when they are reduced to the single reified disease category of 'depression', even when that assumed objective entity is accounted for by a bio-psychosocial model.

The tell tale sign of the ontic and epistemic fallacies in the biopsychosocial models is when it is offered mechanistically to explain the causation of embodied but unchallenged psychiatric categories. Take the example again of 'schizophrenia'. If and when multiple causal mechanisms for 'schizophrenia' are offered alone then there is a telling silence about a range of questions of interest to critical realists. What about a social analysis of the history, function and conceptual validity of that category? What about the role of categorisation in eugenic thought? What about the professionalisation of psychiatry and its need to emphasise medical authority over a presumed biological illness? By ignoring these questions a form of naive realism, emerges, expressed in the name of the biopsychosocial model (Bentall et al. 1988).

Thus, arguably all that has happened with the bio-psychosocial model is that single factor aetiology has been displaced by a multi-factor alternative, without any critical interrogation being in play about psychiatric diagnosis and treatment as social phenomena. Given that functional psychaitric diagnostic categories have such poor justificatory criteria (they lack conceptual and predictive validity, they lack treatment specificity and their etiology ipso facto remains unknown) why do they survive? That question can only be answered by a critical realist interrogation. An unending etiological search, even within a bio-psychosocial model is oblivious to that requirement.

A Model not a Theory

The two core features of the bio-psychosocial model (non-reductionism and biographical sensitivity) are attractive to patients and to practitioners with psycho-social sensibilities, but a couple of critical clarifications are invited. First, this is an eclectic and pragmatic model not a coherent theory. It was certainly very close to tenets of GST when championed by Engel (1977; 1980). However, its close professional linkage with the inter-disciplinary project of (Meyerian) social psychiatry indicates that other influences were evident, which were separate from GST.

Second, even if it is defended within a framework of GST (which it can be) this theory can be expressed and embraced in a variety of ways. For example, as we have just noted it can be limited to the emphasis on multi-factorial causality. By foregrounding the latter, other important emergent qualities of human action can fade into the background. An emergent quality of human communication systems is that their reflexive capacity creates explicit systems of goals and values at the collective level and meaning at the individual level (Wilden, 1980). Consequently, any form of knowledge production about human beings, which only deals with causes but not goals, values and meanings is partial and inadequate.

This then is the main risk of the bio-psychosocial model- any epistemological or methodological closure, which deals only with causes, might exclude reflexivity and reproduce forms of naive realism. Rather than persuasively displacing the medical naturalism bestowed by Kraepelin, the danger is that it simply replaces it with a more comforting comprehensive version of that legacy for researchers and practitioners. For example, Engel (1977) was explicit about this point about revising, not attacking, the medical model (for emphasis, see the title of his paper):
 To provide a basis for understanding the determinants of
 disease and arriving at rational treatments and patterns of
 health care, a medical model must take into account the
 patient, the social context in which he (sic) lives and the
 complementary system devised by society to deal with the
 disruptive effects of illness, that is the physician role and the
 health care system. This requires a biopsychosocial model.
 (Engel, 1977:129, emphasis added).


Thus the focus is on the determinants of diseases (as natural givens) and a plea for an enlarged medical model, notwithstanding the stricture to 'take into account' the psychosocial layers contextualising the patient's experience.

Reviewing this starting point after 25 years, Borrell et al. (2004) argue that the model has established itself as 'a philosophy of clinical care and as a practical guide' (ibid:576). They go on to plead for a greater involvement than in the past of the patient's subjective perspective on their illness, arguing that this is particularly relevant in the case of mental illness. But neither Engel nor these supportive revisionists of the bio-psychosocial model provide a critique of a diagnostic approach within the psy complex or question its much-attacked role in relation to stigma and social regulation. The reason for this silence is that the focus of the bio-psychosocial model is all too readily the patient-in-context, not the role of the psy complex or its taken-for-granted diagnostic constructs. Critical reflexivity is thus missing with negative consequences for the aspirations of a full GST approach to mental life.

Reflexivity and pluralism

An implication of reflexivity for human science is that we would expect individuals and communities of interest to generate a plurality of synergistic and antagonistic accounts. This outcome was noted by Foucualt in The Order of Things(1973), when he pointed out that in the modern episteme, human science operates in the ambiguous spaces between three main plains of inquiry: the reflective conclusions of philosophy; the predictions of the a priori sciences (like maths); and the careful descriptions and deductions of the a posteori sciences (like geology) (Foucault, 1973).

The alternative account offered of this ambiguous outcome from critical realism is to do with the normative and historically-situated challenge for human science (compared to the natural sciences). What post-structuralism and critical realism have in common, despite their more general antagonism about the relationship between ideas and reality (Craib, 1997), is the shared commitment to ongoing critical reflexivity. By contrast, naive realism, including versions of the bio psychosocial model, which focus only on causes, celebrates scientific incrementalism; the assumption that knowledge becomes more complete and certain in a linear fashion over time.

The pluralism noted above is not just about contestation in the academy of the social sciences about questions of ontology, epistemology and methodology. There we certainly find unending disputes in the major boundaried disciplines of sociology, psychology and anthropology but it is also about professionally-codified knowledge. In the case of the bio-psychosocial model, this largely refers to arguments within and between clinical psychology and psychiatry. Tensions between these two groups emerged as the former made bids for legitimacy to encroach on medical territory. This inter-professional turf war is then fed by academic contestation. Then it becomes not just a battle about ideas but also about salaries, occupational status and legal powers (Burgess and Blashfield, 2007).

The latter point was noted at the start of this paper in relation to the professional project of psychiatry at the end of the 19th century in its bid for legitimacy, involving an interweaving of medical jurisdiction in the administration of the asylum system, assumed biological causation and eugenics. Social psychiatry and its attendant biopsychosocial model emerged as an interdisciplinary response to this claimed biomedical authority. It is beyond the scope of this paper to read the development of the bio-psychosocial model within a framework of the sociology of the professions but such a reading is important to note here, as part of the overview of the model's existence and credibility.

Clinical professionals derive their authority in large part from their claims of expertise with all the implications of power over others this invites and justifies (i.e. patients, who are the focus of their clinical gaze, and colleagues in other professions). Moreover, professional expertise feeds on claimed certainties and is threatened by humility and self-doubt. None of this is a propitious starting point for critical reflexivity in the health care professions. Note the quotations cited earlier from Engel and Borrell-Carrio and colleagues, in which the bio-psychosocial model is being offered inter alia as a strategy for increased professional credibility. They are saying to their bioreductionist colleagues that if medical dominance is to survive, then doctors should get smarter; the bio-psychosocial model could help achieve this aim. However, if the bio-psychosocial model ends up being merely an upgraded medical model, with no capacity for critical reflexivity, it still replicates closed-systems reasoning. Its open-systems potential remains a rhetorical prospect.

Conclusions

This paper has traced the roots of the bio-psychosocial model in 'mental health care'. A range of theoretical developments, from GST in biology to Meyer's biographical approach within psychiatry, informed the model. Its open-textured character (it is a pragmatic model for clinical practice and research, not a theory) also allowed it to incorporate elements from sociology, which emphasised both causes and meanings.

These strands have been marshaled to provide a more comprehensive account of illness behaviour, than that offered by a narrow somatic approach. However, because of its overwhelming focus on the determinants of disease, and the unique features of particular patient presentations, the model has little or nothing to say about professional concepts and legitimacy. These have been taken as natural givens; such unreflective naturalism then can generate forms of naive realism, which add to, rather than supersede, the older medical model. Accordingly to date, despite its increased comprehensiveness about the determination of illness, it would seem that the bio-psychosocial model has not fulfilled the promise implicit to radical forms of GST.

An optimistic scenario for the future would be the development of a bio-psychosocial model which opened itself up to the interrogation of critical realism, given that the latter is compatible with GST. If the bio-psychosocial model has been sustained demonstrably by a range of theoretical influences from social science, this one from realist philosophy might also now be incorporated beneficially. If this took place, then practitioners would need to provide formulations, which were not limited to their biographically-situated accounts of particular patients. Additionally they would question critically their own professional interests, role in society and preferred constructs. This meta-account of the professional-patient interaction might help fulfill the potential of a model which still has much to offer.

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David Pilgrim (1), Peter Kinderman (2) and Sara Tai (3)

(1) University of Central Lancashire

(2) University of Liverpool

(3)University of Manchester

Corresponding author e-mail address: DPilgrim@uclan.ac.uk
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