the biopsychosocial model is not a strawman

7/28/2019 The Biopsychosocial Model is Not a Strawman

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Michael Alan Schwartz, Aaron L. Mishara, and Osborne P. Wiggins, "The Biopsychosocial Model Is Not A Strawman: How Jaspers'Phenomenology Opens The Way To A Paradigm Shift In Psychiatry," Existenz 6/1 (2011), 1724 First posted 4-6-2012

Volume 6, No 1, Spring 2011 ISSN 1932-1066

The Biopsychosocial Model is not a StrawmanHow Jaspers' Phenomenology Opens The Way to A Paradigm Shift In Psychiatry

Michael Alan SchwartzTexas A&M Health Science Center School of Medicine, Austin State Hospital

[email protected]

Aaron L. MisharaThe Chicago School of Professional Psychology

[email protected]

Osborne P. WigginsUniversity of [email protected]

Abstract: Inheriting the nineteenth century division between the natural- and human-historical sciences, Karl Jaspersemphasizes the psychological understanding of mental disorders as narrative-based, holistic and contextual.However, he also affirms the value of explanatory physiological and neurobiological approaches. Nassir Ghaeminonetheless interprets Jaspers person-centered, methodologically based pluralism as contradicting George Engel'sbiopsychosocial project. In our view, Jaspers advances this project. Emphatically, Engel proposed a project and nota product. We have tried to develop a narrative somewhat different than Ghaemi's, with a synergistic consequence,a biopsychosocial model for medicine and psychiatry indebted to both Jaspers and Engel. It is our conclusion thatJaspers' person-centered, methodological pluralism does not contradict biopsychosocial medicine and psychiatrybut in fact complements and advances the broader medical model that Engel sought but never achieved.

Nassir Ghaemi's essay1 makes short work of GeorgeEngel's biopsychosocial psychiatry. According to Ghaemi'strenchant analysis, Engel's model for psychiatric practiceopposes a falsely narrow conception of biology and

1 S. Nassir Ghaemi, "The Biopsychosocial Model in Psychiatry:A Critique," Existenz 6/1 (2011), 18. [Henceforth cited as BMP]

consequently cannot withstand the present-day resurgenceof modern biological dogmatism; it misunderstands themind/body relationship; "if true, it is trivial" and noadvance beyond Osler; it muddies boundaries as well asthe difference between etiology and treatment; it falselypresumes superiority for psychiatry over allied healthprofessions; and it is an unfit approach for teachers; payersand managed care in general. Far better, for Ghaemi, is a


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Existenz: An International Journal in Philosophy, Religion, Politics, and the Arts

http://www.existenz.us Volume 6, No 1, Spring 2011

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non-eclectic, pluralistic model for psychiatry based (so heclaims) upon the seminal ideas of Karl Jaspers.

We begin this response by agreeing with Ghaemi'stwo major assertions. Present-day biopsychosocialmedicine and psychiatry are deeply flawed, and Jaspers'existentially informed, pluralistic, and method-basedpsychiatry offers corrective direction. Nonetheless, weand Ghaemi have substantive disagreements. Ghaemiinterprets Jaspers person-centered, methodologicallybased pluralism as contradicting Engel's medical project.In our view, Jaspers advances this project. Emphatically,Engel proposed a project and not a product, and wereEngel alive today and witness to the "silos" (biological,psychological and social) of present-day biopsychosocialpsychiatry, he would doubtlessly wonder what ifanything all this has to do with his work. Indeed, Engelwas well aware of the "silophication" lurking in the term"bio-psycho-social" (the tendency to concretize the term

and then have medicine divided up into three parts).Engel abandoned biopsychosocial for about a decadeand replaced it with "infomedicine." He writes in 1987,"the very word biopsychosocial, as though linking threeentities, all too readily pulls one back towards theclassical Newtonian-Cartesian position, a tripartitedualistic re-edition ofpsychosomatic orpsychophysiological."2Anticipating a broader, more integrative practice ofmedicine, Engel called for "medical revolution" suffusedwith "postmodern scientific thinking," and for this taskthe term biopsychosocial was "clearly inadequate" (SMRviii). Later on, toward the end of his life, still searching

for a way and presumably disappointed with"infomedicine," (we can only speculate as to why as thereis no reliable source for the reasons for Engel'sdiscouragement), he returned to the term"biopsychosocial."3 Once again, as we will see below, theterm remained a call rather than an outcome. Ghaemi, aswe will also see below, is unsympathetic topostmodernism, and Engel's appeals to postmodernscience are one of the major foci of Ghaemi's critique. Atthis point in our essay, we will only comment that

2 George L. Engel, "Foreword," in Laurence Foss and KennethRothenberg, The Second Medical Revolution: From Biomedicineto Infomedicine, Boston/London: New Science Library,Shambhala 1987, pp. vii-x. [Henceforth cited as SMR]

3 George L. Engel, "From Biomedical to Biopsychosocial: BeingScientific in the Human Domain,"Psychosomatics 38/6 (1997), 521-8[henceforth cited as BTB]. Originally published as "Foreword"in Robert Charles Smith, The Patient's Story: Integrated Patient-Doctor Interviewing, New York/Boston: Little, Brown 1996.

Ghaemi's criticism of Engel, curiously dissociated as itis from any historical context, is strikingly postmodern.

We have our own disagreements with Engel, andwe will return to them in this essay. Akin to Ghaemiwe are indebted to Karl Jaspers. Nonetheless, whileJaspers' critique of present day practice remains fresh inmany ways, we have difficulty aligning it withGhaemi's critique. In the first place, we do not thinkthat the sharp boundary drawn by Ghaemi betweenJaspers and postmodernism holds as securely asGhaemi presupposes. At its core, postmodernisminvolves a call for criticism and skepticism; we find asimilar clear call in the work of Jaspers. Secondly (andmore importantly for the present commentary), wedissent from Ghaemi's billiard ball metaphor"a balfor each hole"for proper medical and psychiatricpractice. A ball for each hole? A method for eachproblem? Here, choice of method is "based on empirica

data (as available) and on conceptual soundness(otherwise)?" Yes, that could be one, highly abstracand reductionistic pluralistic approach to a methodbased psychiatry (and quite different from eclecticism)Then, based on data and logic, Patient A could get hermedication, and patient B his evidence-based form ofpsychotherapy, and Patient C a social, or perhaps aspiritual approach. And, for patient D we couldreserve, serially following Ghaemi, medication andthen psychotherapy. In all cases, less would be moreManaged care would be pleased, and preference wouldcede place to science, evidence, and conceptual rigor. So

what is wrong with all of that?Let us begin by examining Ghaemi's argument

more closely. In our reading, Ghaemi is making twoclaims, which he states are unrelated to one another, i.e.not dependent on one another: (1) the bio-psycho-sociamodel is no longer useful, and (2) Ghaemi is able to offera useful alternative, a method based psychiatry, whichis consilient with Jaspers' methods as outlined in thelatter's General Psychopathology (first published in 1913).4

Claim (1) rests on a few sub-arguments: The biopsycho-social model is not useful, it has been

misunderstood. Moreover, even properly understoodthe BPS model remains inherently deficient given itspostmodernist cynicism, a pervasive permissivenessthat anything goes. Such permissiveness "represents thecore of the BPS model as applied in psychiatry for the

4 Karl Jaspers, General Psychopathology, transl. Julius Hoenigand Marian W. Hamilton, Chicago: The University ofChicago Press 1964. [Henceforth cited as GP]


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past three decades" (BMP 2). Here, while agreeing thatpermissive eclecticism is problematic, we will notfollow Ghaemi's dismissal of postmodernism. We agreewith Ghaemi that the biopsychosocial model isproblematic as presently practiced, but we find remedyfor this inadequacy precisely in methodologicalguidance initiated by Jaspers.

Claim (2) rests on the following assumptions:Ghaemi's method-based psychiatry resembles Jaspers'methodology because it is able to place each billiardball in the right pocket. Here, we will ask how suchmethodology is able to do thiswithout relying on theexpertise or clinical decision making of thepractitionerand provide an alternative. We providethe alternative interpretation that Jaspers'phenomenology leads precisely to the appropriation ofa bio-psycho-social-spiritual model but now informedby collaboration with new disciplines such as clinical

neuroscience and philosophical and evolutionarybiology in a person centered medicine.

As Ghaemi himself has stressed,5 in hismethodology, Jaspers makes room for both causalexplanatory natural science and a human-historicalscience of understanding (e.g., biographicalunderstanding). That is we are able to approach humanexperience from both the neurobiological andphenomenological levels without giving priority toeither, without reducing one to the other. In fact, Jasperslaments in his GP the currenteven in his day!decrease in the general level of education of psychiatrists

in the humanities, and thus failure to employ apsychology of understanding in clinical practice which,as a result, has become crude and oversimplified.6

Jaspers writes about the "givenness of the innerworld not perceived by the senses"by directlyintuitively re-presenting it to ourselves and describingit (anschaulich vergegenwrtigen und beschreiben), or whathe calls "the intuitive making present of the mental"

5 S. Nassir Ghaemi, The Rise and Fall of the BiospsychosocialModel, Baltimore: The Johns Hopkins University Press, 2010.

6 See Karl Jaspers, "Kausale und 'verstndliche' Zusammenhngezwischen Schicksal und Psychose bei der Dementia Praecox(1913)," in Karl Jaspers, Gesammelte Schriften zurPsychopathologie, Springer: Berlin/ Heidelberg /New York 1963,p. 336. [Henceforth cited as ZSP] Translated and reprinted, Karl

Jaspers, "Causal and 'meaningful' connexions between lifehistory and psychosis," in Themes and Variations in EuropeanPsychiatry, eds. Steven R. Hirsch and Michael Shepherd,Charlottesville, VA: University Press of Virginia 1974, pp. 81-93, here p. 90. [Henceforth cited as TV]

(anschauliche Vergegenwrtigung des Seelischen). Thatis, the mental realm requires its own methodology, an"understanding psychology," where the understandingof the connections is done through a newunderstanding of things as in the work of Nietzsche(ZSP 336). We leave for the moment theepistemological status of the resultant general mentastructures that the phenomenological method opens upand explores (noting some differences between Husserand Jaspers). Jaspers writes:

genetically understood connections are connectionsformed by ideal types, which are in themselves notinductively obtained but evident in themselves, andserve as standards by which the currently actualprocesses may be assessed and recognized as moreor less understandable rather than directlycontributing to theories. [ZSP 332, our translation]

Drawing on the work of his contemporaries, such asBrentano, Dilthey, Husserl, Simmel, Weber, and othersJaspers emphasizes that

we understand psychic connections, how the mentalarises from the mental, e.g., how actions arise frommotives, how moods and affects arise situations andlived-experience to the extent we ascribe internalstates as underlying motives to observed behavior weare making understanding connections psychologicallyor empathically (einfhlend) empathic understandingis psychology itself. [ZSP 330, our translation; and TV83, translation modified]

In contrast, Ghaemi, conceptualizes Jaspers interms of an "either-or" approach, which seems tocoincide with his billiard ball analogy of getting thecorrect ball in the correct hole. He writes that: "Jasperswas a biological reductionist too and also sometimes anexistential reductionist. That is what I mean when I sayhe is not eclectic, and this is the alternative to BPSeclecticism that has not been understood by manypsychiatrists and philosophers Jaspers might say'This is billiards. Each ball belongs in its own hole'"(BMP 7).

In our view, this is not what Jaspers says. A carefureading of Jaspers and his fellow phenomenologists(leaving for the moment, the interesting internadisagreements between them) points us in a completelydifferent direction than Ghaemi suggests. For exampleGhaemi writes, "Method-based psychiatry maintainsthat only one theory is correct, but it is not the same onefor all parts of psychiatry" (BMP 8). In our view, Ghaemi'sbilliard ball analogy not only does not capture the spiriof Jaspers and other phenomenologists' rigorous


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methodological understanding but is actually a recipefor a return to the myopic, silo-like thinking and clinicalpractice of the medical model that Engel and otherswere trying to combat and which today we are finallyovercoming precisely because of the tremendousinterdisciplinary advances and perspectives thatdisciplines such as cognitive, clinical and socialneuroscience, and philosophical and evolutionarybiology have been supporting.

Ghaemi proposes that "choice of method is basedon empirical data (as available) and on conceptualsoundness (otherwise)" (BMP 8), but here Ghaemiobviates the obvious point: there is still the billiardplayer shooting the ball, who somehow knowson thebasis of expertise and clinical decision makingwhichpocket to shoot into.

Here we argue the following two points: (1) Acareful reading of Jaspers and other contemporary and

later phenomenologists leads to precisely the oppositeconclusion: choice of method cannot be determinedexternally or objectively but requires contextual clinicalunderstanding. (2) Permissive eclecticism Ghaemi'spluralistic "ball for each hole" is not the only alternativeto permissive eclecticism (which Ghaemi identifies withBPS and also with postmodernism). Ghaemi's answer, amethod-based psychiatry, is instead a reductionismcontrary not only to Jaspers but also to Husserl as wellas a host of relevant psychiatrists and neurologistsincluding Berze, Binswanger, Blankenburg, Conrad,Ey, Straus, or von Weizscker. Again, we recognize that

Jaspers in his GP sometimes did and at other times didnot differentiate his multiperspectival position fromphenomenology and also from many of the methodsused by these colleagues. Details about such similaritiesand differences cannot be presented here given thescope of this essay.

Here we argue the following two points: (1) Acareful reading of Jaspers and other contemporary andlater phenomenologists leads to precisely the oppositeconclusion: choice of method cannot be determinedexternally or objectively but requires contextual clinical

understanding. (2) Permissive eclecticism Ghaemi'spluralistic "ball for each hole" is not the only alternativeto permissive eclecticism (which Ghaemi identifies withBPS and also with postmodernism). Ghaemi's answer, amethod-based psychiatry, is instead a reductionismcontrary not only to Jaspers but also to Husserl as wellas a host of relevant psychiatrists and neurologistsincluding Berze, Binswanger, Blankenburg, Conrad,Ey, Straus, or von Weizscker. Again, we recognize thatJaspers in his GP sometimes did and at other times did

not differentiate his multiperspectival position fromphenomenology and also from many of the methodsused by these colleagues. Details about such similaritiesand differences cannot be presented here given thescope of this essay.

Let us approach the question of the different kindsof evidence at different levels of analysis by referring toHusserl's approach, also very much influenced by thenineteenth century explanation/understandingmethods debate which not only Jaspers but alsoDilthey, Simmel, Weber and many others at the timestruggled with.

The human sciences (Geisteswissenschaften, the termcan be traced to an anonymous script of 1787)7 arebased on the understanding of meaningful connectionsbetween historical events, whereas the natural sciencesfind causal explanations between postulated naturaentities.8 Figure 1 indicates that natural sciences

generally proceed from larger, often nebulous wholesseeking out explanatory relationships between ever-smaller, strictly defined parts of these wholesExplanation (causal/mechanistic orstatistical/probabilistic or functional/teleological) triesto establish relationships between subcomponent partsConversely, the historical-human sciences generallymove upwards from partial views to ever-largercontexts for understanding the matter at handUnderstanding is contextual by situating parts ingreater wholes, even if these totalities are not directlyavailable to the individual perspective but transcend or

"encompass" it.9 For example, the historical-humansciences themselves stand in a historical process, whichis at the same time the object (as contextual totality) oftheir study.10

7 Alwin Diemer, "Geisteswissenschaften," in HistorischesWrterbuch der Philosophie, Vol. 3, ed. Joachim Ritter, Basel:Schwabe Verlag 1974, 211-5. We are indebted to Dr. HelmutWautischer for this point.

8 Aaron L. Mishara, "Missing links in phenomenologicalclinical neuroscience? Why we are still not there yet,"Current Opinion in Psychiatry 20/6 (2007), 559-69.[Henceforth cited asMLP]

9 Karl Jaspers, Reason and Existence, transl. and intr. WilliamEarle, New York: Noonday 1955.

10 Hans-Georg Gadamer, Truth and Method, 2nd edition, transland intr. Joel Weinsheimer and Donald G. Marshall, NewYork: Continuum 1993.


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Figure 1

Methods of the natural and the human-historical sciences

, physis ()physical-natural sciences

, bios ()biological sciences

, psyche ()psychological-cognitive sciences

, polis ()historical-cultural sciences

Here the contextuality of understanding and explanation isschematically demonstrated. Assuming an opposed directionalitybetween explanation (the arrow is pointing to the smallest circle) andunderstanding (the arrow points away from smallest circle), themethods of the natural and human-historical sciences are indicated.Natural sciences proceed in terms of the classic reductionisthierarchy from sociology to psychology, biology, chemistry andphysics. These generally proceed from larger, rather nebulous

wholes to seek out explanatory relationships between ever-smallerparts of these wholes. Conversely, understanding is contextual bysituating parts in ever-greater wholes, even if these totalities areultimately unavailable to the individual perspective but transcend orencompass it. Each discipline requires an abstraction, reduction to,and idealization (i.e., Husserl's "naming") of the objects or entities ofits discipline (which exclude the objects of neighboring disciplines).Gray areas between disciplines indicate interdisciplinaryrelationships which are often more fuzzy involving destabilizingrelationships within interdisciplinary vocabulary and concepts.11

Hence, any claim to unify the natural and humansciences is burdened by seemingly insurmountableproblems. These include the integration of two

opposing directions of method, and the effort necessaryto make the contextual understanding of subjectiveexperience somehow objective and testable in the termsof natural scientific explanation, i.e., in terms of thecognitive and neural processes and mechanisms.

11MLP 564, figure reprinted with permission from WoltersKluwer Health.

This dilemma is reflected in what Levine andnumerous philosophers following him, call the"explanatory gap" between neural processes andqualia,12 i.e., what it is like to experience phenomenastates. In contrast to Ghaemi's billiard ball metaphor ofa method-based psychiatry, the explanatory gap (andthe attendant explanation understanding controversycontinues to be a problem.

However, this does not preclude that we are ableto spontaneously shift attitudes from contextuaunderstanding to hypotheses about underlyingneurobiological contributions in our clinical practice orclinical research. Although completely opposed indirectionality, they do not contradict each other asGhaemi's billiard ball holes (Ghaemi's "silophication"that are kept separate from interdisciplinarycollaboration and research.

Rather the opposing directionality of methods

between explanation and understanding stand in adialectical relationship, what Jaspers' Heidelbergcolleague and founder of psychosomatic medicine inGermany, Viktor von Weizscker,13 called the"revolving door principle" of a Gestalt-circle: thoughmutually exclusive as abstractions, the two termsexplanation and understanding, mutually presupposeone another.

Jaspers, along with Binswanger, Blankenburg, vonWeizscker and other colleagues did recognize theneed to approach the relationship between explanationand understanding dialectically or contextually in

clinical practice. We find that this resonates with recenefforts to establish a person-centered medicine. Webelieve that the proposed paradigm shift to a morephenomenological-clinical neuroscience will provide amore holistic, narrative, strength based (empowering)contextual, culturally sensitive approach andeventually, a new understanding of mental disorders.

Viktor von Weizscker had argued that we mustintroduce the concept of the subject into the study of life(biology). However, as human beings, we are able toreflect on our own subjectivity, but do not have access

to the hidden unity between mind and body in whatvon Weizscker called the fundamental relationship

12 Joseph Levine, "Materialism and qualia: The explanatorygap," Pacific Philosophical Quarterly 64 (1983), 354-61.

13 Viktor von Weizscker, Der Gestaltkreis; Theorie der Einheitvon Wahrnehmen und Bewegen, 4. Aufl., Stuttgart: GeorgThieme Verlag 1950. [Henceforth cited as GK]


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(Grundverhltnis) to our own being. Mind and body arerather experienced as two sides of the same coin. Thatis, mind and body are in hidden unity or a Gestalt-circle(Gestaltkreis), that is, each term presupposes butmutually excludes the other. This unity is not givendirectly to consciousness and thus remains in hiddenrelationship (Grundverhltnis). The comparison betweenJaspers and von Weizscker recalls the thoughtprovoking comparison between Jaspers and Engel thatGhaemi poses. Both von Weizscker and Engel wereinvolved in overcoming mind body dualism and wereopen to psychoanalysis. Both were convinced that theonly way to do so was not to ignore the natural sciencesbut to integrate them into a more contextual holisticeffort. All threeJaspers, von Weizscker, and Engelwere convinced of the importance of human meaningin autobiographical understanding, and how thesemeaningful connections may be disrupted in different

disorders (and now that we are discovering theunderlying processes, including molecular processesunderlying the memory for self we are coming closer totheir vision). Here we must agree with Jaspers but alsohis contemporaries (Brentano, Dilthey, Husserl,Simmel, Weber, and others) on the same point: "weunderstand psychic connections, how the mental arisesfrom the mental, e.g., how actions arise from motives,how moods and affects arise situations and lived-experience" (ZSP 330, our translation; and TV 83,translation modified).

Unfortunately for Ghaemi's metaphor, medical

and psychiatric practice is not akin to an instrumentalgame such as billiards. While it is often possible andeven appropriate to reduce the subject of medicinethe person(s) centered promotion of health andamelioration of illnessesto one abstract aspect oranother, all abstract moments must always be relatedback to the whole. Our patients are concrete humanbeings with all of the world relatedness that this entails.And while our sciences can indeed appropriately focusupon a singular abstract moment taken from this whole(for example, a hemoglobin A1C or a formal thought

disorder), physicians must never lose sight of the wholeto which this part nonetheless refers. Each perspectivedoes reflect back upon that whole, and as a perspectiverather than an answer. In his GP, Jaspers tirelesslyasked the reader to be mindful of all of the perspectives,and the manner in which they reveal, conceal,contradict and complement each other. Furthermore,there will be other perspectives, some not yet disclosed.Always cautious, he was skeptical of the verypossibility of there being correct balls for each hole.

And finally, for all of the perspectives,understanding halts (never nullifying their correcapplication). If there is a game that is being played, it isnot billiards, but life.

Ghaemi does open a door to such existential factsof life by permitting existential approaches, presumablywhen appropriate, but his singular, or serially singularone-ball-for-each-hole methodology cannot suffice, wewould argue, for a Jaspers-informed practice. Such amethodology is too abstract, the perspectives tooreified, and their application too concrete, apart fromgenerating the kind of silophication that Ghaempresumably wants to overcome by doing away withthe BPS model. We would further argue that JaspersGPthe very text that Ghaemi warns beginners awayfromstates all of this.

GP was written when Jaspers was 30 years oldand it went through several editions through his life

the most pertinent perhaps being the 1946 editionwritten in Germany during the WWII years whenJaspers was not permitted to work and lived day byday with his Jewish wife awaiting a knock on the doorand arrest and worse. Herein, Jaspers embraces whatoday would be called a person-centeredmethodologically pluralistic framework for psychiatryWe do agree with Ghaemi that Jaspers program is quitedifferent from the eclecticism and silos of present daybiopsychosocial psychiatry. But it also differs fromGhaemi's notion of a proper method, or sequence omethods, per problem. Rather than contradiciting

Engel's quest for a broader, more inclusive medicapractice, we emphasize that Jaspers existentiallyinformed methodological pluralism should be viewedas advancing it.

How does this fit into Ghaemi's billiard game? Wesuggest that Ghaemi is playing the wrong gameGhaemi's instrumental game is neither person centerednor people centered, it is task or procedure orientedgetting the correct ball into the correct hole. Indeedsometimes medicine and psychiatry sometimes mayappear task oriented (for example, developing a

vaccine for an illness), but even in these case the goamay be better achieved through sanitation or alteringsocial mores. Indeed there are many ways to get toRome, and although acknowledging this may appear tobe kowtowing to postmodernism (so relative!), in thehuman world (and even on the billiard course, in so faras billiard is a human game) such is truth.

The reality of psychiatry as a scientific andhumanistic endeavor is indeed a starting point forJaspers' GP, who would agree with Ghaemi that:


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We are asking for a systematic grasp of all theexisting methods and viewpoints and insist thatthere should be no confusion of them, and nogeneralization beyond certain well-defined limits,and within these limits methods should besystematically used and carefully applied. [GP 34]

Nonetheless, in distinction to Ghaemi's ball per hole:

my own over-all point of view starts, not from anapparently known, factually demonstrable principleof things, but rather points down many perspectivesand in many directions. It suggests movement invarious planes and constrains us to remain alert andlook far afield, while at the same time we try to keepa firm grip on all the systematised knowledge wehave won so far.

Our attempt takes the form only of acomprehensive methodology, in which all possibleknowledge can be accommodated. Such amethodology must be so constructed that it is an

open one which constantly allows for new methods.The basic attitude expressed in this book is that

of fighting against all attempts to create absolutesWe want to understand and accommodate all theknowledge that is possible and find a natural placefor it within the framework of our method. [GP 35]

In the end, in his seventh edition of GP, at age 76,Jaspers defended his book as one that "does not seem tobe out of date," with "methodological principles" thatremain "largely unaffected." Still, nonetheless, "it wouldcertainly be possible nowadays to write a better book

even on the methodological side. Such a task must fallto a younger scientist who might well succeed if hewould appropriate the methodological clarification ofthis book, expand it, and put it perhaps into a differentcontext. I would gladly welcome such a book."

Hence, in this essay, we have tried to develop anarrative somewhat different than Ghaemi's, with asynergistic consequence, a biopsychosocial model formedicine and psychiatry indebted to both Jaspers andEngel. It is our conclusion that Jaspers' person-centered,methodological pluralism does not contradictbiopsychosocial medicine and psychiatry but in factcomplements and advances the broader medical modelthat Engel sought but never achieved. Beginning withvery different presuppositions and premises, operatingin very different medical worlds, and utilizing verydifferent approaches, George Engel and Karl Jaspersboth tried to rescue medical (in Engel's case) andpsychiatric (in Jaspers' case) practice from improperreductionist approaches, methods, and dogmas. For alltheir different yet complementary programs, both saw

a proper medical starting point in a collaborativeprofessional relationship, in so far as that is possiblebetween a physician and a patient (with all theirsubjectivity and world-relatedness) for the sake ofadvancing their health and ameliorating their illnessAnd then what? Writing in the preface to his 1942edition of GP, Jaspers states:

Everything, which has been contributed to theknowledge of the sick human psyche bypsychiatrists in the main, but also by generalphysicians, psychologists, psychotherapists,biologists and philosophers, has needed to beanalysed in respect of its basic features and alsofound a place within a realistic classification. [GP xi]

And in his final 1997 BTB essay, Engel began witha 1933 quote from H.S. Jennings: "We include asbiology not only the data obtained by observing otherindividuals and things but also those that we reachthrough [our own inner experiences of living]. Thebiologist is himselfof the same material of which arecomposed the living things that he studies."14

Before we close, we will disagree with Ghaemi'sdepiction of George Engel as a resolutelyantihumanistic physician-scientist (or psychoanalyticpseudoscientist). Yes, Engel does call for physicians tobe as scientific as possible, but we must ask ourselvesprecisely what he has in mind. Rather than banninghumanism from the medical domain, Engel's intentionit seems to us, is that biopsychosocial thinking provides

a conceptual framework conducive to accommodatingthe human domain scientifically. At age 84, in order toclarify his meaning, writing his last published essayfrom a senior citizen facility (to which he had gone tolive earlier, still healthy and working each day, so thahe could reside with his infirm wife), Engel offers us anexcerpt from his own idiosyncratic personal diary as apotential source of legitimate scientific evidence: Onenight he cannot sleep consequent to an annoyingsensation in his throat, changing his bedtime posturedrinking water and belching several times brings reliefin the morning he is "a little sad" as he recalled how his

currently very ill wife would have "noticed that I sliddown (and) would try to help me get repositionedbefore symptoms developed. She has been in a nursinghome for more than a year." Pertinently for goodmedical practice, "experienced clinicians using

14 Herbert S. Jennings, The Universe and Life, New Haven, CT:Yale University Press 1933, pp. 14, 22.


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observation, introspection, and dialogue can beremarkably successful in documenting the existence ofexplicit pathological bodily processes and associatednondisease issues first inferred simply from what thepatient had to say" (BTB 525). Engel goes on to end hisfinal essay with the acknowledgement that in 1997, itvery much remained an open question whether thenarration (in contrast to interrogation) that hisapproach entailed did or did not fall within the scope ofscience. "But characteristic of science is also surprise."One day, for example, technology (at this point in hisessay Engel was referring to improved audiovisualtechnology) could possible "render feasibleoperationalizing the methods of study of the particularengagement between physician and patient that yieldsthe primary data (e.g., interviewing)." And on that day,we would "rejoice in the discovery.!"

In conclusion, we agree with Ghaemi that the

present silos of biopsychosocial medicine andpsychiatry fail to conform to Jaspers' robust, personcentered methodological pluralism, but we must addthat they are equally lacking from the vantage ofEngel's new paradigm project. We further agree withGhaemi's conclusion that Engel never comprehendedJaspers' methodology, but instead inappropriatelyrejected it as "old paradigm thinking." What Ghaemifails to see, as did Engel, is the prospect that Jaspers'person centered methodological pluralism can in factadvance Engel's project. It is our position that Jaspers'person-centered methodological pluralism provides

both the direction and the tools for present and futurebiopsychosocial practice in medicine and psychiatry.

the biopsychosocial model is not a strawman

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