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The bio-bio-bio model of madnessJOHN READ wonders what happened to the ‘psycho’ and ‘social’ in explanations of mental illness.

ON 19 August 2005 the AmericanPsychiatric Association publishedan article, in Psychiatric News,

entitled ‘Big Pharma and AmericanPsychiatry: The Good, the Bad, and theUgly’ (see tinyurl.com/97g7j). It stated:

There is widespread concern at theover-medicalization of mental disordersand the overuse of medications.Financial incentives and managed carehave contributed to the notion of a‘quick fix’ by taking a pill and reducingthe emphasis on psychotherapy andpsychosocial treatments. There is muchevidence that there is lesspsychotherapy provided by psychiatriststhan 10 years ago. This is true despitethe strong evidence base that manypsychotherapies are effective used aloneor in combination with medications… If we are seen as mere pill pushers andemployees of the pharmaceuticalindustry, our credibility as a professionis compromised. (p.3)

Printing this dissident viewpoint, directlycounter to international (particularly US)thinking for the past three decades, was acourageous move by the APA. It remindedme of the late Loren Mosher’s magnificentletter of resignation from the APA in 1998:

Psychiatry has been almost completelybought out by the drug companies. TheAPA could not continue without thepharmaceutical company support ofmeetings, journal advertising,luncheons, unrestricted educationalgrants etc. Psychiatrists have becomethe minions of drug companypromotions… No longer do we seek tounderstand whole persons in theirsocial contexts – rather we are there torealign our patients’ neurotransmitters.(www.moshersoteria.com)

What was astonishing about this revival ofMosher’s concerns was that it was not justanother rebel screaming at the indifferenceof his profession before resigning – it wasSteven Sharfstein, the APA President.

As if in response to Mosher’s call to

‘Get real about science, politics and money.Label each for what it is,’ Sharfstein added:‘Drug company representatives bearinggifts are frequent visitors to psychiatrists’offices and consulting rooms. We shouldhave the wisdom and distance to call thesegifts what they are – kickbacks and bribes.’

The first time I attended a psychiatryconference, of the Royal Australian andNew Zealand College of Psychiatrists yearsago, I was sickened by the extent of thedrug industry’s presence. Among theendless stalls distributing ‘gifts’, perfectyoung bodies in skintight bodysuits

pranced around enticing psychiatrists tohave ‘free’ massages. My announcing thatthere were more company representativeslisted as delegates than psychiatrists fromthe whole of New Zealand was met withstony silence.

Last year I broke my vow never toattend such conferences again and went tothe World Psychiatric Association Congressin Florence. The dominance of the drugcompanies was reflected in the ‘scientificprogramme’, which contained little otherthan drug studies. After one of my papers(‘The treatment of psychosis in the contextof childhood trauma’) a psychiatrist fromScotland stood up to say: ‘Calm down,John. You are winning. We get it. Thingsare changing.’

But are we winning? What wouldwinning mean? At a conference inVancouver last year Dr Robin Murray gave an encouraging plenary address. Heacknowledged some of the recent researchabout the role of psychosocial factorsinfluencing schizophrenia. He concluded,however, that ‘the schizophrenia wars wereover years ago’. He was referring to thetruce established under the banner of the‘bio-psycho-social’ model, which says thatschizophrenia is an interaction between a genetically inherited predisposition andthe triggering effect of social stressors.

But I think the war is far from over. I explained that in most wars the invadingpower is premature in announcing acessation of hostilities, usually once theyhave reduced the inhabitants of the invadedcountry to uncoordinated, sporadicresistance. I said that many of us still feelwe are living in occupied territory. The warwould end, I continued, only whensimplistic biological ideologies andtechnologies withdrew to the appropriateboundary and acknowledged the damagecaused by their illegitimate incursion.

In 2004, along with 23 other contributorsfrom six countries and a range of disciplines(including service users), I published whatwas consciously intended as a coordinatedcounter-attack in the ‘war’. In the openingchapter of Models of Madness:Psychological, Social and BiologicalApproaches to Schizophrenia, my co-editors(Richard Bentall and Loren Mosher) and I make our intentions quite clear. We arguethat the heightened sensitivity, unusualexperiences, distress, despair, confusionand disorganisation that are currentlylabelled ‘schizophrenic’ are not symptomsof a medical illness. The notion that ‘mentalillness is an illness like any other’,promulgated by biological psychiatry andthe pharmaceutical industry, is not supportedby research and is extremely damaging tothose with this most stigmatising ofpsychiatric labels. It is responsible forunwarranted and destructive pessimismabout the chances of ‘recovery’, and hasignored – or even actively discourageddiscussion of – what is actually going on inthese people’s lives, in their families, and inthe societies in which they live.

Models of Madness brings together thebody of evidence that will increase theconfidence of the majority when faced withthat misguided but powerful minority whoproclaim with all the trappings of scientificand professional expertness: ‘It’s an illness– so you must take the drugs’, by force ifnecessary. I say ‘the majority’ becausenumerous international surveys show thatthe public (like most mental healthprofessionals and their clients), when asked what causes schizophrenia, citesocial factors such as poverty and traumatic

‘The war is far from over…Many of us still feel we areliving in occupied territory’

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childhoods, far more often than bio-genetic factors (Read & Haslam, 2004).

Psychologists, like other academics and health professionals, tend to be ratherthoughtful and kindly folk. Most prefer notto engage in wars, of any kind. So it isunderstandable that so many psychologistshave accepted the so-called bio-psycho-social model. It allows psychologistsinterested in schizophrenia to study whichpsychosocial factors trigger the supposedgenetic predisposition, as long as they areprepared to ignore the absence of reliabilityor validity for the construct they arestudying (Bentall, 2003). It permits clinicalpsychologists to help ‘schizophrenics’manage their symptoms and preventrelapses by encouraging families to lower their ‘expressed emotion’ (an oddeuphemism for hostility and criticism).Anyway, why bother with the tedious old nature–nurture battle now we knoweverything is an interaction of the two?

Nevertheless, the supposed integrationof perspectives implied by the term ‘bio-psycho-social’ model since the 1970s ismore illusion than reality. An integral partof this has been the ‘vulnerability-stress’idea that acknowledges a role for socialstressors but only in those who alreadyhave a supposed genetic predisposition.Life events have been relegated to the roleof ‘triggers’ of an underlying genetic time-bomb. This is not an integration of models,it is a colonisation of the psychological andsocial by the biological. The colonisationhas involved the ignoring, or vilification,of research showing the role of contextualfactors such as neglect, trauma (inside andbeyond the family), poverty, racism,sexism, etc. in the etiology of madness.The colonisation even went so far as toinvent the euphemism ‘psycho-education’for programmes promulgating the illnessideology to individuals and families.

I admit to a barely suppressed ‘Yes!’when I read Sharfstein’s comment ‘Wemust examine the fact that as a profession,we have allowed the bio-psycho-socialmodel to become the bio-bio-bio model’.So perhaps things really are changing. On a good day I can see plenty of evidence.The international consumer/survivormovement is alive and well (Chamberlin,2004). British cognitive psychologists areleading a renaissance of the involvement ofpsychologists in the psychosis field, an areawe largely abandoned after the introductionof antipsychotic drugs in the 1950s. Theyare demonstrating not only that

hallucinations and delusions are perfectlyunderstandable in terms of normalpsychological processes (e.g. Garety et al.,2001) but also that cognitive therapy iseffective for psychosis (e.g. Kingdon &Turkington, 2005) – with or withoutmedication (Morrison et al., 2004). Severalother psychological approaches have alsobeen proven effective (Martindale et al.,2000; Read et al., 2004).

Researchers around the world are less afraid to study psychosocial factors,including the near taboo subject of familydysfunction (Read, Seymour & Mosher,2004) as causal agents in the etiology ofpsychosis, rather than as mere triggers orexacerbators of an imaginary or, at best,grossly exaggerated genetic predisposition(Joseph, 2003). Poverty (Read, 2004),urban living (van Os et al., 2001), racism(Karlsen & Nazroo, 2002), other forms of

discrimination (Janssen et al., 2003), childabuse (e.g. Read et al., 2003; Read et al.,in press) and having a battered mother(Whitfield et al., 2005) have all beenshown to be highly predictive of psychosis.Some even dare to speak of schizophreniaas being preventable via universalprogrammes enhancing children’s safetyand quality of life (Davies & Burdett, 2004).

There are other positive signs. I havespoken to full houses at the first two Britishconferences on trauma and psychosis, ourbook has received positive reviews inpsychiatric journals, and the InternationalSociety for the Psychological Treatments of the Schizophrenias and other Psychoses(www.isps.org) has grown enormously.

The true measure of progress, however,is on the front line of practice. Theemerging pockets of excellence across theUK must be brought to the attention ofmanagers still harbouring the industry-sponsored notion that drugs are always thefirst-choice treatment. The simple truths arethat human misery is largely inflicted byother people and that the solutions are bestbased on human – rather than chemical orelectrical – interventions. If mental healthservice users were involved in negotiatingthe final truce in the ‘schizophrenia wars’,the bio-bio-bio model would be history.People like choices.

■ Dr John Read is in the PsychologyDepartment, University of Auckland, NewZealand. E-mail: j.read@auckland.ac.nz.Homepage: tinyurl.com/chwzb.

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News analysis

Bentall, R. (2003). Madness explained:Psychosis and human nature. London:Penguin.

Chamberlin, J. (2004). User-run services.In J. Read et al. (2004). Hove: Brunner-Routledge.

Davies, E. & Burdett, J. (2004). Preventing‘schizophrenia’: Creating theconditions for saner societies. In J.Read et al. (2004). Hove: Brunner-Routledge.

Garety, P. et al. (2001).A cognitive modelof the positive symptoms of psychosis.Psychological Medicine, 31, 189–195.

Janssen, I., Hanssen, M., Bak, M. et al.(2003). Discrimination and delusionalideation. British Journal of Psychiatry,182, 71–76.

Joseph, J. (2003). The gene illusion. Ross-on-Wye: PCCS Books.

Karlsen, N. & Nazroo, J. (2002). Relationbetween racial discrimination, socialclass and health among ethnicminority groups. American Journal of

Public Health, 92, 624–631.Kingdon, D. & Turkington, D. (2005).

Cognitive therapy of schizophrenia. NewYork: Guilford Press.

Martindale, B., Bateman, B., Crowe, M. &Margison, F. (Eds.) (2000). Psychosis:Psychological approaches and theireffectiveness. London: Gaskell.

Morrison,A.P., French, P.,Walford, L. et al.(2004). Cognitive therapy for theprevention of psychosis in people atultra-high risk. British Journal ofPsychiatry, 185, 291–297.

Read, J. (2004). Poverty, ethnicity andgender. In J. Read et al. (2004). Hove:Brunner-Routledge.

Read, J.,Agar, K.,Argyle, N. & Aderhold,V.(2003). Sexual and physical abuseduring childhood and adulthood aspredictors of hallucinations, delusionsand thought disorder. Psychology andPsychotherapy: Research,Theory andPractice, 76, 11–22.

Read, J. & Haslam, N. (2004). Public

opinion: Bad things happen and candrive you crazy. In J. Read et al. (2004).Hove: Brunner-Routledge.

Read, J., Mosher, L. & Bentall, R. (2004).Models of madness. Hove: Brunner-Routledge.

Read, J., Seymour, F. & Mosher, L. (2004).Unhappy families. In J. Read et al.(2004). Hove: Brunner-Routledge.

Read, J., van Os, J., Morrison,A.P. & Ross,C.A. (in press). Childhood trauma,psychosis and schizophrenia: A literaturereview with theoretical and clinicalimplications. Acta PsychiatricaScandinavica.

van Os, J., Hanssen, M., Bijl, R. &Vollebergh,W. (2001). Prevalence ofpsychotic disorder and communitylevel of psychotic symptoms. Archivesof General Psychiatry, 58, 663–668.

Whitfield, C., Dube, S., Felitti,V. & Anda, R.(2005).Adverse childhood experiencesand hallucinations. Child Abuse andNeglect, 29, 797–810.

References

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