Psychotherapy at the Crossroads
A New Vision of Integrative Mental Health
By Andrew Weil
Epidemic depression is occurring at a time when the field of mental health appears very robust. There are more mental health professionals treating more people than ever before in history: psychiatrists, clinical psychologists, licensed social workers, counselors, and therapists of all kinds. We have a powerful "therapeutic arsenal" of drugs to make us happier, calmer, and saner. When I leaf through the pharmaceutical ads that take up so much space in psychiatric journals, I get the feeling that we should all be in great emotional health. Depression and anxiety should be as fully conquered as smallpox and polio. But more of us than ever are discontented and not experiencing optimum emotional well-being. What is wrong with this picture? Why is the vast enterprise of professional mental health unable to help us feel better?
I want you to consider the possibility that the basic assumptions of mainstream psychiatric medicine are obsolete and no longer serve us well. Those assumptions constitute the biomedical model of mental health and dominate the whole field.
In 1977, the journal Science published a provocative article titled "The Need for a New Medical Model: A Challenge for Biomedicine." I consider it a landmark in medical philosophy and the intellectual foundation of today's integrative medicine. The author, George L. Engel, M.D., was a professor of psychiatry at the University of Rochester (New York) School of Medicine. Determined to overcome the limiting influence of Cartesian dualism, which assigns mind and body to separate realms, Engel envisioned medical students of the future learning that health and illness result from an interaction of biological, psychological, social, and behavioral factors, not from biological factors alone. He fathered the field of psychosomatic medicine and devoted much of his career to broadening our understanding of disease. He was particularly interested in mental health.
George Engel died in 1999 with his vision largely unrealized. In fact, the field of psychosomatic medicine ran out of steam sometime before his death and was never able to challenge the ascendancy of biological medicine.
"Biology Explains All" was in full swing when I was a student at Harvard Medical School in the late 1960s. At that time, I was taught that just four diseases were psychosomatic: peptic ulcer, rheumatoid arthritis, bronchial asthma, and ulcerative colitis. Four out of the entire catalog of diseases is not a lot, but at least for those four, doctors conceded that mental/emotional factors played a role. Peptic ulcer was knocked off the list in the early 1980s when a bacterial infection (Helicobacter pylori) was identified as the "real" cause of ulcers, now treatable with antibiotics. Investigation of biological factors associated with the three remaining conditions has led to more powerful drug treatments for them and greatly lessened interest in attending to any psychological, social, or behavioral factors that might be involved. Rheumatologists today, for example, are most enthusiastic about a new class of immunosuppressive drugs called TNF-α blockers, which often appear to put rheumatoid arthritis and ulcerative colitis into full remission. Never mind that these drugs can be highly toxic and are very expensive; once doctors prescribe them for these conditions, they no longer see the point of addressing emotional or lifestyle factors of the patients who have them.
Although George Engel's efforts in psychosomatic medicine were ahead of their time, their relevance today is great, and I advise all health professionals, especially mental health professionals, to read his 1977 paper in Science. I will summarize his "challenge for biomedicine" here, because it exposes the great limitations of the conceptual model that now dominates medicine in general and psychiatric medicine in particular. …