Three cheers, and a minor quibble.

I am here to praise Caesar, not to bury him.

Well, not Caesar, really; the good Dr. Makari is my subject.

I saw this in the NYT a few days ago and found myself singing hosannas. The upshot is that in the relentless push to destigmatize psychiatric illness, our fearless leaders decided that we must stick to the party line that psychiatric conditions are diseases, and diseases are biological, and the organ affected is the brain. Therefore, since diseases are “real,” we could convince everyone that the stigma is irrational. It didn’t work, near as I can tell.

Dr. Makari takes this apart in a thoughtful, cleanly-argued way with the obvious authority of a clinician. Hats off, doc.

Not only do I think this failed, I think it played into the wrong hands as well. One way it’s done that is to reinforce the idea that psychiatrists do the “biological” stuff and other people do the other stuff. Which means psychiatrists are paid to spend 15 minutes with their patients asking strictly about doses and side effects, rather than dealing with the actual complexity of psychiatric cases.

This is another post, but I rather think many of our troubles in health care stem less from not considering the biology of psychiatric illnesses; but rather in not thinking of medical conditions in the way we have considered psychiatry. Do we really think that increased education, social support, and reinforcement of functional behaviors works only for psychotic disorders, but not for diabetes? Don’t you believe it. The best cardiologist I ever saw spent about 1 minute talking about cholesterol meds, and about 10 minutes going through people’s diets and how much time they spent sitting. (The guy could smell an anxiety disorder from five rooms down, too. A true Jedi, that one. Our loss, cardiology’s gain.)

My quibble, though, is with the universally cited, nearly universally misunderstood, and sadly misapplied “biopsychosocial model.” Dr. Makari seems to be telling us our failing is in not adhering to it. I think our failing is that we still try.

My quibbles are both practical and theoretical. The theoretical one is that it’s not a model. It makes no testable predictions at all. If it does much that is useful, it might define different levels of explanation, and encourage us to consider each possible level in dealing with a clinical situation. I’m not sure that’s any better than simply being told, “You should take everything into account.” I call that good advice, not a model.

The practical gripe, which is more a problem with us than the model itself, is that we just renamed dualism so we could feel a little better about it. I take as evidence the constant use of the word “psychosocial” in medical parlance, as in, “We must also consider the psychosocial component to this.” Note:

  1. The psychosocial component, as if there is only one.
  2. Ever hear somebody talk about the bioppsychological aspects? The sociobiological aspects? Me neither.

A teacher of mine, a highly experienced consult-liaison psychiatrist, once facetiously remarked that there was a monosynaptic reflex in internal medicine residents which linked the recognition of a psych thing with a call to the psychiatry consult service. I think “psychosocial” has turned into the psych thing of our medical culture. It means important, but not-disease, not-quite-medical, not us.

So we now have an implicit dualism renamed in “biopsychosocial” terms. This breaks down quickly in real life. In addictions, there’s a pill called disulfiram. If you drink, it makes you sick; and it’s given to people with alcohol addictions to deter them from drinking. It is, basically, a pharmacologic implementation of something like punishment or an avoidance schedule. So it’s a behavioral intervention that is done by altering the person’s alcohol metabolism. In what box do we put that? Biological? Psychological?

We could go through similar thought experiments with stuff like methadone, bariatric surgery, psychotherapies for headache, and on and on.

Dualism by any other name is still dualism. It didn’t work, but renaming it doesn’t mean we dumped it. You replace ignorance with understanding, not reductionism and marketing.

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