The biopsychosocial model between biologism and arbitrariness. A Commentary to H. Helmchen

In his article “Different conceptions of mental illness: consequences for the association with patients” Helmchen rightly cautions against any kind of dogmatism in psychiatry, regardless of whether it is a social, a psychological or a biological one. Instead, he favors the biopsychosocial model as a remedy for “the narrowing of conceptions that depict only partial aspects of mental illness” (Helmchen, 2013, p. 3). The main criticism of this model is traditionally that it “borders on anarchy” because one can emphasize the “bio” if one wishes, or the “psycho” [. . . ], or the “social.” There is “no rationale why one heads in one direction or the other” (Ghaemi, 2009, p. 3). Against this alleged arbitrariness and vagueness of the integrative model Helmchen recommends basing it “on scientifically proven concepts” (Helmchen, 2013, p. 4). Yet, it is not quite clear in which relation the three elements of the integrative model should stand and what its proposed grounding on scientifically proven concepts amounts to. I assume that the biopsychosocial model either has to be based on biological facts or else it will remain arbitrary. But if it is based on biological facts—even if not exclusively—it will probably be charged with “biologism” in just the same way as current accounts of biological psychiatry. It is certainly true that a dogmatic overemphasis of the physiological side of the disorder-coin is ill-advised and in all likelihood to the disadvantage of the patient. Whether biological theories of the mind are in fact utterly brainfocused is, however, a point of contention. Admittedly, there are indeed voices that urge the concept of mental illness to be replaced by an account of brain disease (Bickle, 2006; Akil et al., 2010; Holsboer, 2010; White et al., 2012). But the vast majority of biological psychiatrists does try to understand the patient’s personal situation. Even a hardboiled reductionist cannot avoid asking the respective patient about what she “feels.” The reason is simply that it is up to now impossible to read off the brain whether someone feels depressed or not, whether she has delusions or not. The causes of a mental illness on the one hand and the symptoms on the other are to be found on different levels. This points to the distinction between “explaining” and “understanding” Jaspers is so often cited with and which even a biological psychiatrist cannot—and will not—ignore. In his General Psychopathology Jaspers explains: