Outline for an Externalist Psychiatry (1): Or, How to Fully Realize the Biopsychosocial Model

Abstract: The biopsychosocial (BPS) model in psychiatry has come under fire for being too vague to be of any practical use in the clinic. For many, its central flaw consists in lack of scientific validity and philosophical coherence: the model never specified how biological, psychological and social factors causally integrate with one another. Recently, advances in the cognitive sciences have made great strides towards meeting this very ‘integration challenge.’ The paper begins by illustrating how enactivist and predictive processing frameworks propose converging accounts of biopsychosocial integration that are far superior to those of previous theories. It argues, however, that the main problem of implementing the BPS model has less to do with integration than with the lack of a social etiology. Psychiatric practice leans heavily towards ‘bio’ and ‘psycho’ approaches, without an equally developed set of explanatory and therapeutic resources for dealing with the ‘social’ dimension of illness. This leaves psychiatry essentially internalist in orientation. As illustrated most poignantly by conditions such as functional neurological disorders, internalism comes with the risks of stigma and the curtailment of therapeutic possibilities. The paper argues that the answer to the failings of the BPS model lies in combining the integration challenge with the development of an ‘externalist psychiatry,’ which casts both causes and treatment of psychiatric illness onto the social environment. The following two papers explore the conditions that might make this idea a reality.