Although most clinicians now recognize the need to integrate biological, social
and personal factors in psychiatric care, efforts have been hampered by the lack of a comprehensive theory. Eclecticism
is not sufficient, as it neglects to indicate when one framework might be more important than another in the cause
or treatment of a particular disorder. The enormous economic and human cost of experimentation in the clinical
and social sciences indicates the need to utilize theoretical approaches. On the basis of systems theory, G. L.
Engel (The clinical application of the biopsychosocial model. Am J Psychiatry 1980; 137:535-544) proposed a sequential
biopsychosocial approach, while K. H. Pribram (The neurobiologic paradigm, in Models for Clinical Psychopathology.
Edited by Eisdorfer C, Cohen A, et al. New York, Spectrum Publications, 19815) advocated that treatment can start
at any point, since to change any part is to change the whole. Both of these concepts are at variance with sociological
and sociobiological formulations, all of which recognize that social processes precede the development of personal
individuality in the history of the species as well as of each person. This approach is based on the concept ofbiological priority and psychological supremacy
advanced by process theory.
According to this approach, the biological level needs to be addressed first, as survival precedes all other needs
in time and is least influenced by choice. Basic needs such as survival, respiration, and nutrition have priority
in time but are dominated by the more complex levels as the simpler needs are partially met. This leads to a flexible
approach, in which one level or another may be the predominant one at a given time. For instance, restoring breathing
always has absolute priority, but once life is not threatened, taking care of the patient's emotional well-being
may become more important than treating a respiratory difficulty. Conversely, attending to the emotional welfare
of a dying patient has absolute supremacy. Note that social processes precede personal ones. Social role precedes
the individual manner in which one performs it. Before knowing each other as individuals, women and men, employer
and employee, and patient and doctor face each other as a function of their respective roles. The difference between
process and systems approaches has significant consequences regarding clinical and social practice. Process theory
implies that social factors should be given great weight in understanding the pathogenesis of illness, away from
the traditional individualistic approach. By implication, family therapy should be employed more frequently and
earlier than individual therapy.
The dynamic concept of a sliding scale of priority : supremacy contrasts with more rigid schemes that oppose different
levels of organization such as needs and wants derived from biological instincts (id) versus social repression
introjected as a superego. Actually, false needs and wants introjected by society play a repressive role, a more
comfortable, pleasant and democratic form of social control. Only the simplest needs are mainly biologically determined.
All others are socially conditioned in their intensity, quality and form of satisfaction. Thus, society can create
false needs through market oriented media, entertainment and advertisement. Olds demonstrated that rats which can
self-stimulate their brain pleasure centers through implanted electrodes will do so for long periods of time, to
the detriment of all other activities. Similarly, humans exchange immediate gratification of pleasurable needs
(e.g., smoking) for long-term goals. The need to be successful or useful drives many to work beyond the limits
advisable for good health or for successful family life.
Complex processes such as thinking and valuing, relating to others, and creating are dependent on simpler physiological
processes. These basic processes precede, coexist and set limits within which the complex operates; hence, the
material and energetic aspects of the problem usually, but not universally, need to be dealt with before the informational,
subjective aspects, the ideas, values, and emotions. This means addressing objective life circumstances before
subjective feelings and conceptions, biological illness before interpersonal psychological disorders, social and
family matrices before personal intrapsychic processes, and the facts as they appear before the meaning ascribed
to them by interpretation. However, process theory points out that the more complex processes can override the
simple ones. It also alerts us to the fact that one is not confined to operating linearly, but, in fact, one must
attend at the same time to the supremacy of the social and psychological aspects. Without trust and compliance
there can be no treatment. Unfortunately, treatment may also be limited by insurance, illustrating the supremacy
of the social over the biological.
The concept of biological priority : psychological supremacy particularly applies to insight. Insight is considered
a basic psychotherapeutic technique but it is just as important in biological medicine. Whether in medicine or
psychiatry, biological insight has priority. When a material reality exists and operates, whether it is perceived
or not, it is necessary to facilitate the patient to gain insight --so reality can be dealt with appropriately.
The initial step in dealing with a biological problem might be providing awareness that a physiological problem
does indeed exist. As the patient who denies the meaning of his or her chest pain will not seek the needed treatment,
the patient suffering from a genetically determined affective disorder cannot be adequately treated unless he or
she is aware of the diagnosis. Therapists who promote "insight" into hypothetical unconscious factors,
childhood traumas or current family conflicts while denying the importance of biological factors, provide no insight
at all.
Biological insight must be complemented with social and psychological insight. In our practice we increasingly
witness patients with obvious problems such as unemployment, job insecurity, marital conflict, and childhood abuse
who are treated with antidepressants because they are economically more convenient for the physicians and the drug
industry that dominates our medical practice.
The priority : supremacy concept contrasts with the philosophical materialism of biological psychiatry, which postulates
the primacy of matter, and with philosophical idealism of non-biological psychology which postulates the primacy
of ideas. Implying the coexistence of opposites, each predominating in a different respect, the priority : supremacy
paradigm provides a method for integrative patient care.
