Does Psychiatry Need Narrative Theory?
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narrative, Paul Ricoeur, Biopsychosocial model, positivism
Ishare Dr. Bolton’s view that the 4P model works within the spirit of the Biopsychosocial model while offering certain advantages. While reading about the 4P model, I was struck by the distinct advantages that narrative theory confers to those working in the Biopsychosocial spirit. But, I fear that my take home message about narrative theory runs counter to Dr. Bolton’s intention in writing about the 4P model. After all, Dr. Bolton cites an exaggerated sense of the importance of theory as an important reason for the failure of the Biopsychosocial model, and Dr. Bolton characterizes the 4P model as being ‘shorn of high theory.’ But, although medicine may emphasize the empirical over the theoretical, I believe the empirical work done in medicine is predominantly guided by positivist theoretical assumptions that run counter to the Biopsychosocial spirit. The fact that these theoretical assumptions remain implicit combined with a general antipathy toward explicit reflection on theory makes it all the more difficult to call positivist theoretical assumptions into question. Alas, calling into question the ‘common sense’ positivist theoretical assumptions that guide medicine remains an important part of the task facing those who want to advance the Biopsychosocial spirit. So, although I want to underscore some of the narrative virtues of the 4P model, I also feel the need to demonstrate that, especially for those of us who want to advance the spirit of the Biopsychosocial model, it is important to be theoretically explicit.
Dr. Bolton notes that the 4P model employs a series of why questions to emplot the narrative of the case formulation. This is an important point to which I want to return, but before turning to why questions, it is important to consider the role of a what question. Just what is the nature of the problem we are trying to explain with our why questions? The importance of theoretical assumptions becomes quite evident here. I have characterized the 4P model as working within the Biopsychosocial spirit. It is a spirit that finds the demand to work solely within the purview of, as Dr. Bolton succinctly surmised, “simple, linear causal sequences” (2014, 180) to be stultifying and ultimately impractical. Because the 4P model considers clinical problems to be complicated, as opposed to simple, it turns to a broad array of explanations and takes the normative stand that ‘thicker stories’ are ‘better stories.’
However, not everyone is working under the same theoretical assumptions. For example, a thinker like Samuel Guze would find Dr. Bolton’s statement that the 4P model emphasizes prognosis over diagnosis to be a logical contradiction. Guze [End Page 203] would probably simply assert that ‘diagnosis is prognosis.’ Guze helped to pioneer the notion that prognostic specificity is an important validator of a diagnostic construct in psychiatry (Robins and Guze 1970). His ideas in this regard were influential for the neo-Kraepelinian turn that psychiatric nosology took with third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and they remained influential in the recent fifth revision of the DSM. Guze presents a good foil for the purposes of my argument for a couple of reasons. Guze self-consciously embraced the ‘medical’ model in opposition to the Biopsychosocial model, and Guze considered his work to be free of any theoretical assumptions. Guze could therefore assert without any sense of self-contradiction, “The medical model is without a priori theory, but does consider brain mechanisms to be a priority” (Compton and Guze 1995, 200).
I would characterize Guze’s assumption that diagnosis reflects a brain mechanism that will determine prognosis with law-like regularity as being entirely consistent with the theoretical tenets of logical positivism. In other words, not only is diagnosis a type, it is a type that can be subsumed under a causal law. The methodological hierarchy of evidence-based psychiatry that prioritizes the value of randomized, controlled trials seems to be guided by similar assumptions. It could be that part of the reason that Guze failed to recognize his own theoretical assumptions is because the medium is the message. The message conveyed...
