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| PRESIDENTIAL ADDRESS |
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| Year : 2020 | Volume
: 2
| Issue : 1 | Page : 3-6 |
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Psychiatry – From Biological Reductionism to a Bio-Psycho-Social Perspective
Roy Abraham Kallivayalil
Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Tiruvalla, Kerala, India
| Date of Submission | 16-Jan-2020 |
| Date of Acceptance | 17-Jan-2020 |
| Date of Web Publication | 21-Mar-2020 |
Correspondence Address:
Prof. Roy Abraham Kallivayalil
Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Tiruvalla - 689 101, Kerala
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/WSP.WSP_4_20
Understanding the social paradigm of health and especially mental health is important to the physician today. The approach in Ayurveda and in ancient Greek was person centred, focusing on quality of life and health rather than disease. Biological factors can be fully understood only when applied along with natural sciences and this is essential for progress in Medicine. Biological reductionism happens in psychiatry when we try to over-simplify human behaviour, neglecting the complexities of the mind. Our approach in psychiatry has traditionally been medical or biological. This approach continues, despite the evidence base for such reductionism not being inspiring. On the contrary, biopsychosocial model is concerned with the experience of not only illness but also health and the individuals with their health problems and environment are viewed holistically. In contrast to the biomedical approach which takes a reductionist view, the biopsychosocial model does not prescribe a unitary approach, but tries to understand different clinical scenarios at several levels in a continuum. The need tody is to study what happens between people rather than what is wrong with an individual wholly detached from a social context. This should happen without ignoring the existing neuro-biological and psychological dimensions. Mental illness does not become mere failure of an individual, rather it is product of the society to which he/ she belongs.
Keywords: Biological reductionism, biopsychosocial, psychiatry
How to cite this article:
Kallivayalil RA. Psychiatry – From Biological Reductionism to a Bio-Psycho-Social Perspective. World Soc Psychiatry 2020;2:3-6 |
Delivered at the 23rd World Congress of Social Psychiatry, Bucharest, Romania, 25-28 October, 2019
“We know what we are but not what we may be.”
— Ophelia in Hamlet
“The greatest discovery of my generation is that human beings can alter their lives by altering their attitudes of mind.”
— William James
| Introduction | |  |
The origin of social psychiatry dates back to ancient civilizations. If one were to look into the considerations for adding a social paradigm of health, it would be that it gives a holistic framework to psychiatry as well as health. The WHO defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. It is important for the modern-day physician to identify and understand the social paradigm of health, more so from a public health standpoint, and this goes a long way in the curative, preventive, and promotive aspects of managing health and more so mental health.
If one examines the ancient textbooks, the focus of the physician in Ayurveda is on the patients' health rather than the disease. There is a harmonious framework for health and life and a greater emphasis on quality of life rather than just the curative aspect of disease. The approach in Ayurveda and in ancient Greek philosophy is person centered and takes into consideration the person as a whole. This concept is clearly stated by Socrates, “If the whole is not well, it is impossible for the part to be well.”
Psychological and social factors are intertwined with social sciences. Similarly, biological factors can be fully understood only when applied along with natural sciences. Hence, medicine can progress only if both natural and social sciences are considered as its essential pillars. Biological correlates can be fully explained only if psychological and social factors are dealt with, in a scientific manner and not treated as mere epiphenomena or as secondary symptoms.
| Biological Reductionism in Psychiatry | | |
Reductionism is an approach to understanding the nature of complex things by reducing them to the interactions of their parts, or to simpler or more fundamental things. Such reductionism happens in psychiatry when we try to oversimplify the human behavior, neglecting the complexities of the mind. When we try to reduce human behavior to a physical level and explain it in terms of neurons, neurotransmitters, brain structure, etc., it paves way for biological reductionism. Some believe that symptoms and signs of mental disorders, whether it is depression or abnormal behavior are caused by genetic factors, neurobiological correlates, malfunctioning brain circuits, and other biological factors.
This is because our approach in psychiatry has traditionally been medical or biological.
The biological approach also offers a more “simple” and the so-called “real” medical ways of explaining the symptoms or experience of mental illness to the patient, which also claims to be a less stigmatizing approach.[1] This approach continues despite the evidence base for such reductionism not being forthcoming or inspiring. In 2013, nature editorial concluded that “despite decades of work, the genetic, metabolic, and cellular signatures of almost all mental syndromes remain largely a mystery”.[2]
| the Need for Shift Toward Biopsychosocial Approaches | | |
The biopsychosocial model is interdisciplinary in nature and considers biological, psychological, and socioenvironmental as important. It examines these factors not only in disease but also in health and human development. Thus, George L Engel who proposed this model in 1977 encouraged multifaceted thinking.[3],[4] This model has limitations and has received criticisms, but it continues to exert tremendous influence in shaping our thinking not only in psychology and psychiatry but also in varied fields such as health and human development.[5] Biopsychosocial model is concerned with the experience of not only illness but also health. It studies people's genetic makeup (biology), mental health and personality (psychology), and sociocultural environment (social world). The individuals with their health problems and their social context and environment are viewed holistically.
The evidence for social determinants of health playing a major role in the genesis of both physical and mental illness is substantial.[6] The structural abnormalities that lead to dysfunction – the focal point of biological reductionism – usually arise in the context of human beings growing up and developing within societies and specific cultures, and their upbringing and learned interactions defining their behaviors. It is important that the focus shifts to the more holistic way of looking at the person, rather than just the dysfunction. The earlier definitions of health by the WHO, focusing on just the “absence of diseases”, have been criticized arguing that it does not include the social domain and individuals' ability to manage one's life by fulfilling their potential and obligations with a degree of independence.[7] This is all the more relevant now that the people are living longer with comorbidities, and with many conditions, people can be well at times and ill at other times. It can be argued that health is a dynamic balance between opportunities and limitations, directly affected by social and environmental conditions. In addition, the social domain is highly pertinent in our understanding and management of psychiatric disorders and can be seen as a crucial etiological factor.[8]
The psychosocial interactions and social environment and difficulties at these levels can lead to psychopathological and behavioral dysfunctions in many domains, and this is of crucial importance during the developmental years of a child. The theory of stress diathesis often points to a change in the brain homeostasis with mounting social stressors. According to Virchow, illness (of any kind) was an indictment of the political system and that politics was nothing other than medicine on a large scale.[9] There is a key role that the patient–doctor relationship has on the therapeutic outcome in every medical specialty, more so in psychiatry. The outcome of a treatment can be influenced by patients understanding, expectation, and explanation of the illness. It is important that the doctor takes into account these factors for a successful outcome of treatment. Social factors are important at every stage of human development starting from the prenatal stage, or even earlier, when wider environmental factors are considered. Importantly, they may provide us with clues toward more preventive public strategies in reducing psychiatric morbidities.[10] The biopsychosocial model does not prescribe a unitary approach but tries to understand different clinical scenarios at several levels in a continuum. In contrast, biomedical approach takes a reductionist view trying to explore changes at the cellular or molecular levels to explain various mental phenomena.
There are multiple reasons why social psychiatry has not occupied a prominent space in mainstream medicine, despite the relevance it holds in the current era. The growing influence of pharmaceutical industry on the practice of psychiatry has been a major hurdle. The main stream research in biological psychiatry is funded by pharmaceutical companies. Research in social psychiatry continues to remain underfunded. Despite having path-breaking evidence to look at the relevance of social and cultural context, we continue to look for biological reasons to explain etiology and pathogenesis. This also makes way for an overreliance on drugs despite having evidence for psychosocial interventions which are effective. There are also attacks on social psychiatry from within and outside the medical profession, which further stifles its growth, development, and influence.
Modern medicine often fails to acknowledge the relevance and importance of social determinants of health. The overemphasis on disease and cure has led to neglect of the preventive and promotive aspects of health. The search for super specialization is leading to fragmentation of medicine, ignoring the whole person when a part alone of the individual is being treated. The dignity of the person under care is sometimes ignored, which can pave way for unethical practices in medicine. The ethical imperativeness for autonomy, responsibility, and dignity of the person involved often becomes a casualty.
Fred[11] proposed the term hyposkillia to explain deficiency of clinical skills. Those afflicted with hyposkillia are ill-equipped to render good patient care. Hyposkilliacs are physicians who cannot take adequate medical history or perform a reliable physical examination. Since they do not see their patients in detail or discuss the histories at adequate length, their communication skills will be limited. Their analysis of problems will be defective, leading to poor management plans. This underlines the importance of person-centered approaches and gathering information about social determinants of health encouraged by social psychiatry, to be incorporated in the teaching and training in medical schools, both during graduate and postgraduate medical education. There is also a need to shift from overreliance on technology to “high touch” medicine, where the individual is seen as a whole, and clinical examination takes the priority over fancy investigations. Social approach to mental illness promotes comprehensive care regardless of diagnosis and chronicity, seeing patients in the setting of their family through home visits and eclecticism in psychiatry.
The United Nations Declaration on universal health coverage (UHC) is the most comprehensive set of health commitments ever adopted at this level. In the decades since the Alma-Ata Declaration, human rights, particularly the right to the highest standard of physical and mental health, have evolved in both substance and content. This understanding of the right to health can now be applied to health policy in an operational, practical, and systematic way and is of particular relevance as countries advance in their commitment to sustainable development goals to achieve UHC by 2030.[12]
Today's research is doing much to untangle intuitive understanding about the complex and subtle ways in which body and mind interact, for example, in the interplay between the gut and the emotions, or maternal stress and child temperament. Accumulating data now indicate that the gut microbiota also communicates with the central nervous system – possibly through neural, endocrine, and immune pathways – and thereby influences brain function and behavior.[13] The challenge now is to pick up these threads and follow them carefully toward clinical utility, sailing carefully between the extremes of overexcitement and premature dismissal.
The biopsychosocial model tries to understand suffering and illness and how it is affected at multiple levels from the molecular to societal. It values patients' subjective experiences as important for diagnosis, care, and management. Thus, it is a philosophy on the one hand, while being a practical guide on the other.[14] The biopsychosocial approach is also providing new directions to global mental health by exploring synergies and opportunities in bridging inequities and inequality in mental health-care services worldwide.[15]
| Future Perspectives | | |
The way ahead is to focus on positive health and positive psychology. There is also a need for a paradigm shift in terms of protective and preventive medicine rather than just curative. The focus has to shift back to resilience, quality of life, and support systems, most of which are ignored in the current medical practice. Shared understanding, shared decision-making, and fostering partnerships with various stakeholders have to become mainstream in the years to come. The need is to study what happens between people rather than what is wrong with an individual wholly detached from a social context. This should happen without ignoring the existing neurobiological and psychological dimensions. There is an increasing need to link them to social phenomena in the patient's life and in treatment. Giving due importance to social aspects will make psychiatry more attractive and give psychiatrists more societal relevance. The biopsychosocial perspective also strengthens us in our fight against stigma. This perspective informs, no one can be insulated from biological, psychological, and social influences which can either positively or negatively influence one's mental health. Thus, mental illness does not become mere failure of an individual; rather it is product of the society to which he/she belongs.
| Conclusion | | |
Psychiatric care needs to be collaborative in nature. We need to interact closely with fellow professionals – physicians, general practitioners, internists, psychologists, social workers, nongovernmental organizations, and others. Many of them criticize psychiatry, often due to the lack of proper understanding. Psychologists criticize psychiatry for biological reductionism, whereas some of them advocate extreme psychosocial reductionism themselves! These gaps in understanding need to be bridged. No individual can be studied wholly detached from his social context. It is not only what happens to a person is important for us but also what happens between people. We need to link neurobiological and psychological dimensions to guide the treatment and management plans. In such case, collaborative work remains the future of psychiatry. Psychiatry may not be a perfect discipline of medicine, but it still remains the most patient centered and humanistic. This gives us a bright hope for the future!
“Psychiatrists function primarily as living, comprehending and acting persons”
--Karl Jaspers (1913)
Acknowledgments
Let me acknowledge the research assistance given by our senior resident Dr. Arun Enara in the preparation of this manuscript.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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