Abstract
A recent paper noted that cases with complex medical, psychological and social interactions generally required more services, yet had poorer outcomes than the less problematic cases [1]. Nonetheless, orthodox medical services tended not to address these issues adequately, even though early intervention had a positive and cost-effective outcome.
The authors suggested that “…[Engel's] biopsychosocial model of disease, in which an assessment of biopsychosocial care needs is made… has not been implemented in standard general health care… The problem seems to lie in the lack of operationalisation of biopsychosocial case complexity” [1], p. 795]. Guided by this model, they derived a grid of 12 factors that grade biopsychosocial case complexity. Screening of routine cases and reallocation of resources indicated considerable clinical advantage even when cases were not overtly psychiatric in nature.
While their efforts were certainly interesting, their grid was not an “operationalisation” of Engel's biopsychosocial model. “Biopsychosocial case complexity,” which is what they measured, does not derive formally from any of Engel's published works, for the very simple reason that Engel did not write themodel for which he is remembered [2]. While he (among many others) suggested that 278 CORRESPONDENCE we need a rational and humanist model of mind–body interaction, he never did more than that. One reason for his failure was that he started with a strong intellectual orientation toward psychoanalysis [3] but this approach is metaphysical and does not afford a basis for dualist interaction. I would argue that a genuinely humanist approach will flow from a dualist interactivemodel, but that is a separate matter.
Engel's ‘biopsychosocial model’ amounted to no more than a rallying call in that direction. Unfortunately, Australasian psychiatry [4] seems to have mistaken the call for the reality of themodel itself [5], encouraging the view that psychiatry is in Engel's debt. That is most definitely not the case. His work was a heartfelt plea for a more considerate type of medicine but nothing he wrote constituted a coherent series of propositions that generated testable predictions relating to the unseen mechanisms by which mind and body interact, i.e., a scientific model for psychiatry.
Science is conducted according to rules, one of which states that people cannot believe just what they like. We are compelled to adjust our ideas according to the evidence, yet the frequent defences of Engel's mythical model indicate little general awareness of the discipline required to advance the science of psychiatry. Instead of an objective neutrality, we see an inexplicable partiality that serves only to retard model development in psychiatry.