Thursday, July 11, 2019

Magical Models - The fundamental absurdity of the biopsychosocial model of health care.

A great deal of intelligence can be invested in ignorance when the need for illusion is great - Saul Bellow, American author.

Models are just that, ideas or physical representations of reality but importantly are not to be confused with reality itself. Our ability to create models provides us with another observation about the very reason why the BPS model is both useful while being fundamentally, even grossly absurd. I also argue that the old biomedical model (BM model) was probably a better one, a scientific one, a testable one. It deserved thought not an outright and hasty rejection. The BPS model on the other hand, because of its grasping at the illusion of 'inclusiveness', is fundamentally untestable and was adopted largely because it looks and feels incorporated while possibly achieving the opposite.

Biopsychosocial model: an interdisciplinary model that looks at the interconnection between biology, psychology, and socio-environmental factors.

Interaction between infers in the human mind separate things, entities or processes that come together in a variety of ways. It's also perceived or feels to us that they can be separated as in actually so. For example, my personal experience of speaking with researchers and clinicians from various fields (clinical science, sociology, philosophy, politics, literacy theory, mathematics, etc, etc) is that biology is reducible (the first of many ironies) to a separate subject and largely, often entirely irrelevant to the study of what are essentially things that biological entities (ourselves and each other) do on a day to day basis. That is, humans, often quite accomplished and intelligent ones, function as if human reality existed apart from and was not influenced by or explained through their own biology. Now ask yourself, can either the psychological or the social exist without biology, not the subject but itself? Like the heat and movement produced by a functioning engine psychology and social interaction are aspects of a functioning biology. That we might emotionally prefer that there is a psychology and a society out there somewhere interacting autonomously (and that this helped us understand and explain it) is just that, an emotional preference, a familiarity with a model that is absurd, greedily reductionist, but feels true. And given that the BM model was discarded primarily for being 'too reductionistic' the BPS model simply repeats the fault while dumping the only necessary component of any biological model - the biology! I recall under a handful of people who when asked could describe the explanatory framework of biology (most have no idea what it means) who then went on to describe what they believed was a unique and insightful understanding of behavior (under a different label).

To help order our thoughts and so make better estimations about reality (in order to build reliable knowledge and satisfy the ethic we all apparently endorse (to help not harm others)) we have to understand the fact that believing we are helping others cannot, in isolation, help us determine whether or not we actually are. That step requires considered and dispassionate thought - In philosophy there is the basic premise of ‘necessary’ and ‘sufficient’ which helps us distinguish between that which is primary (necessary) and that which is secondary (and dependent upon primary factors). For example there is no actual example in reality of a psychology or a social interaction that can exist independent of biology (If it were otherwise a dogs bark could logically exist before or even without the dog). Moreover all behaviours depend upon and are explained by it. If the argument is that 'biology (usually science cannot...) explain everything" (a ludicrous position few seriously entertain) we do know that without it we cannot begin to understand anything at all. It requires repetition (such is our unfamiliarity with the idea) that exactly nothing is ‘real’ to a human before it’s biology is functioning. And, because it seems impossible to so many (to the human imagination), we'll state for clarification that a non functioning biology is called one of two things - dead or non existing. We are our biology and we are its story. And there is no possibility that psychology or social interaction can begin to be functioning or described or understood before a biology is present to produce it (and be modified by its own interactions). Consider any human behaviour. The dementia patient has a debilitated biology which severely limits their psychological and social functioning. Limited psychological and social functioning does not determine biology. Biology interacting determines biology (or 'nature interacting with nature'). If we place a person in isolation we will observe a deterioration in their psyche but that is how we describe a deterioration in their biology (which is the producer of the psychological and social behaviours) due to it being isolated from interaction with other biological entities (which through the very long history of biology is how biology interacted (within and between individual biologies). If you are still so attached to the idea that biology was a subject you took at school and not our own marvellous story (and the basis of everything about you) then perhaps it is easier to use other language. Suit yourself on that point but don't fall to the illusions created by our own species of animal (which displays a deep seated cognitive problem with 'daddy issues'). There are no independently arising psychologies or sociologies. What prompted this brief critique was a colleagues opinion that the most important (largest/greatest) aspect of the BPS model was psychological. That is impossible. Psychological cannot actually be greater than the biology which produces it and all other behaviours. Moreover what we call our individual psychology cannot be greater than society (thousands of other biologies/entities which over time have determined how each individual biology is). It appears to us as though it is true because humans are naturally infatuated with their own thoughts and feelings to such a degree that it is easy to feel (irony again) that thought and feelings are somehow an independently arising and autonomous event. They are important to us, yes. Are they so cardinal as to be able to be greater than all else? That is called solipsism, egocentricity or narcissism. All perfectly understandable through comprehending biology - built selfish out of necessity. Let's not give ourselves further reasons to be so.

To illustrate the problem, at the same conference a study showed that exposing a foetus to higher levels of cortisol tended to make a person hyper vigilant (and tending to respond to health interventions with a negative response (nocebo)). It might then seem as though the mothers ‘psychology’ affected the children when in fact the hormones produced by the mothers biology due to her interactions with the world (perhaps she was the victim of abuse and suffering from PTSD) then affected the biological development of the child. This is later expressed as hyper vigilance in the child. That is how the situation is more accurately understood. However, if we believe the BPS model to be descriptive of reality we can try to comprehend what looks like a primarily psychological phenomena (confirmed through our absurd BPS model) by (irony again) mentally (bias) amputating psychology from biology, an impossibility. If biology does not change we do not have psychology or society. Another way to think of it is that psychology and society are fluctuations in biology both in the immediate sense and over millions of years which has moulded itself to continually reflect what we define as psychology and society. Why is that fact so difficult to comprehend? Individuals never live for more than years whereas their biology is billions of years in the making. How our biology functions reflects its evolutionary history - born without knowledge into a brief life, if any at all, with an opportunity to take part in its continuation. For those who feel this cheapens life consider the opposite - it is its very improbability and brevity that makes it so precious and valued (and gives health providers a career).

The most elegant model does (and has for over 150 years) gone back even further than our individual biology. We know for example that the two essential factors that mould each one of us are the genetics we inherit coupled to the exposure or experience of them (which then, via negative and positive (biological) feedback) influence further development. One might study psychology or sociology (terms invented by us to describe aspects of biology (even though the illusion is of cleaving them away)) but one should be aware that our own minds will want to perform a little ‘magic’ on ourselves. Psychology (more irony) coined the term ‘magical thinking’. Our own neurobiology/cognition has a strong tendency to automatically or reflexively connect two ideas as if one caused the other. Feeling that the two are coherent is all the mind needs to believe they are (whether they are or not). We rarely consider whether or not the relationship was causal or otherwise. More importantly we tend not to query our own minds as to how, even hypothetically, we could test or determine the difference. We do not naturally question our own feelings if they feel true because our own neurology tends to reinforce habits. It is why when you awake tomorrow morning that you have not forgotten everything. Psychology calls this very robust, naturally selected, efficient and highly conforming (biased) cognition heuristic thinking. The BPS model satisfies our need for confirmation. If we want to think that psychology and sociology can be separated from biology we can feel strongly that this makes sense (even when it doesn’t).

The model - evolution via natural selection - has always been socially not scientifically controversial. Humans prefer the illusion of immortality for the very reason that the model explains - we are primarily geared to want to live. If that means adopting illusions in an attempt to be rid of our own cognitive dissonance (I'm mortal (I can die and suffer) but don't want to be) we will be easily led. Even very few evolutionary biologists seem to understand that our own story illustrates why our own lives are a constant dilemma, a stream of choices primarily driven by the need to avoid suffering. But it also explains why we are amused by the absurd. Movies, theatre, comedy, tragedy, poetry, song... We are 'attracted<>repulsed' by that which reflects our own predicament. Running away from the reality might offer temporary solace but that is to chose to embrace ignorance, a dangerous precedent. The mass suicide at Jonestown may have looked like an outlier statistic but it's not entirely unique at all and was possible due to human biology - enough people believed they could escape the death of their own bodies because it was 1. a naturally attractive idea (to survive forever in some form) 2. reinforced through repetition 3. the population was homogenised (few if any questioned what the group considered to be a ‘true’ hypothesis (group think)). Billions of humans believe that they either will or might live on after they die. The only difference at Jonestown was that a prolonged indoctrination period so blurred the line between the instinct to survive and the fantasy of immortality that they killed themselves en masse (note that were humans naturally confident of their fantasies (produced by magical thinking) we would witness the ordinary routine of people 'trying it out' by taking the occasional leap off a cliff. Humans are aware of their own pretenses but too afraid to abandon what becomes by adulthood, a social investment. We all pretend not to notice ridiculous ideas and behaviours for fear of looking 'bad' or standing out. Humans only wish to stand out to be admired not to express 'freedom of belief'.

Belief in life after death is the ultimate example of the easy ability cognitively (imaginatively) amputate one's own existence (psychology) from reality because of the natural drive of biology to live and the ability of the imagination to manufacture ‘magical’ solutions to impossible problems. Vitalism, the belief that biology is propelled (and best understood) by pretending it (and therefore we) is driven by something ‘more than’ biological is remarkably popular (even if people don't know the word) for the same reason. Children demonstrate magical thinking (imaginative play/vitalistic causation) which we endorse as a normal and healthy part of biological development. It is endearing in children, stupid and dangerous in adults. If any human can accomplish the delusion of existing without their own biology (billions do), believing that psychology functions independently from (and is bigger than!) biology (the BPS model) is elementary. As a note it is relatively popular to add a fourth category to the BPS Venn diagram, that of the supernatural or ‘spiritual’. Humans naturally struggle with the concept that how we form ideas (epistemology) is more important than the ideas we form But natural selection awards us another version of an animal's brain, not a philosophers and so the most popular epistemology is confirmation bias, instinct confirming instinct, faith thinking. Even education is used by us to cement what we feel is true. We are not educated inot what we are (only what we'd like to be) and are not given the tools of deliberate self examination (only self promotion). We are truly besotted with ourselves.

Perhaps this is why humans have no greater difficulty with science than with the common story of their own biology. It has, regrettably for us it seems, never promised what most humans naturally desire - immortality/continuing survival - which in philosophical terms is solipsism (I want whatever I feel is true to be true. If reality doesn’t conform I will imagine it does). For example, the title of one of Darwin’s books is On the Origin of Species by Means of Natural Selection. Another title could well be ‘Our Family History - How We've All Made It This Far’. We need this sort of perspective in order to deal with what researchers have continued to reassert with robust research as being our need for tribal identity. Humans have no actual base rate at which they will favour the in group and punish any other. We will just do it. It takes a great deal of intentional self recrimination in order to even begin to compensate for the delusions our own biology presents us.

Evolution is defined as Descent with Modification and more specifically not only species but each individuals inherent anatomy (biology) is the way it is through our common story. And therefore the manner in which it behaves and interacts is formed and modified by the process. If one were to seriously entertain a competent model for health and well being, one which was most likely to be cogent (and humanly honest), generate sound hypotheses and valid research (and ultimately care for people) it would be natural selection. As insulting as it seems for a species to have to mature and confront suffering and mortality, a professional ethic requires only one thing - dispassionate thinking and better models and solutions. Unfortunately many want to be admired for being well credentialed but don’t accept the moral burden or implication it carries. What we call social, even cultural selection is best understood via the only valid model we have - an evolutionary one. To accept something else demonstrates, ironically again, evolution itself, that it does not proceed by giving creatures marvellous intellectual insight but by building marvellously efficient (and therefore exquisitely irrational and reflexive) biological systems. We even have research that shows that the perception of being ‘educated’ can blind the individual to the fact that they will always remain fundamentally a product of their own, largely consciously unaware, biology. As Saul Bellow and many others have remarked, intelligence is largely used in concert with ignorance, to bolster it, not alleviate. 

It is no accident that both psychology and sociology now have fields using the prefix ‘evolutionary’ since trying to understand either without the focus and explanatory filter of the very process that allowed them to exist would be like the delusion (to use a basic thinking tool called analogy) that deep knowledge and understanding of ourselves is derived by denying we ever had parents (if denial seems to fit the bill). Or as is most popular, to pretend our ‘parents’ are gods of some description. This is quite possibly the most naturally cherished type of belief but also a spectacularly infantile one. The greatest irony is that the current BPS model is what we would expect from a species still overwhelmingly reluctant to accept what we all are - mortal parts of nature (an accurate definition which suffers from being unappealing to health practitioners (but helpful (and ethical/moral) to the building of knowledge and therefore the individual and the community). The other direction is to continue to want to grasp at our own and others bewilderment rather than understand it for the simple reason that it takes less effort.


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