Opinion Conceptual competence in medicine: promoting psychosomatic awareness in clinics, research and education 2025 Dirk von Boetticher

Introduction: In recent decades, psychosomatic medicine has developed into a distinct specialty, bringing specific clinical concepts to bear seeking to acknowledge the unity (not the identity) of the mind and body in clinical care. Such concepts form the identity of the psychosomatic field as a distinct discipline and its epistemological status between somatic medicine and psychiatry. Despite the importance of these concepts from an educational and a research perspective, too little attention has been paid to their clinical impact.

Methods: This paper investigated the general nature of concepts and their role and significance in structuring the clinical encounter and care, including consideration of their relevance for the hidden curriculum.

Results: Conceptual competence is defined as a transformative awareness of the multilayered, fallible, and plural nature of human concepts, which have both descriptive and evaluative and action-guiding properties having both an explicit and an implicit meaning. Conceptual competence in psychosomatic medicine entails dealing competently with the mind–body–distinction and the biopsychosocial model (and criticism of it) with respect to the clinical situation.

Discussion: Conceptual research is presented as an autonomous research area and the complement of empirical research, having a descriptive and a normative function: descriptively analyzing the concepts we have and normatively searching for the concepts that we need for the integrated care we strive for.

Open access

 

Several criticisms of the BPS model can be distinguished: it is vague and not testable (5, 44–46); too general and eclectic (46, 47); a mere juxtaposition of causal factors without an integrative framework (48, 49); and not methodological and inapplicable in daily practice (22, 45, 50).

Notwithstanding this criticism, scientific evidence on the plausibility of the model is continuously accumulating (4, 51–54), and it is continuously undergoing conceptual development through various initiatives: referring to nonreductive, supervenience physicalism to fill conceptual lacuna in the BPS model (5); taking greater consideration of cultural aspects (7); taking specific systems into account that should be investigated precisely along the various interfaces (53); emphasizing scientific and clinical particulars, not generalities (52); investigating single pathways among biological (B), psychological (P), and social (S) factors more intensively for their relevance for subjective well-being (S→P and B→P) and objective health outcomes (P→B and S→B) (54); taking greater account of the first- and second-person perspectives, particularly with respect to somatic processes, and of the findings of predictive processing and the embodied self (55).

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It doesn’t look like the author understands the gravity of the criticism. And it seems like he completely left out the possibility of the single pathway of B→B.

 

Sometimes you read stuff and think "wow, I hope this was written by an LLM with a very bad prompt to maximize buzzwords that sound fake profound but actually say nothing". This is one of those times. Just empty buzzword salad, fitting for an empty buzzword pseudoscience which, in their own recognition, is alternative medicine.

I especially love how all the arguments in response to the criticism ignore the criticism, and the claims of scientific evidence all link to opinion pieces with no scientific evidence, and precisely amount to: we are doing stuff, we have been doing stuff, we will keep doing stuff. Which applies exactly to all other forms of alternative medicine based on pseudoscience.

Besides hurting a lot of people and costing trillions, what this stuff mainly does is act as rocket fuel for the conspiracy fantasy crowds, who absolutely huff this junk like it's glue vapor.

 

Oh, please, Father William, why not just go on standing on your head and give us a rest?

 

They are essentially saying:

We accepted the model as true without actually checking. We’ve now checked, and we concluded that it isn’t true. But we still want to use it.​

So they’ve essentially showed that they have no integrity at all.

 

Lol, that has some funny implications:

• Ants have an expectation of death, but certain jellyfish and lobsters don’t.
• Dogs live shorter lives than us because they expect to die sooner.
• We should never tell anyone they have a terminal diagnosis because that might speed things up.

 

I'm pretty certain you will find BPS papers saying just that.

 

A bit of clarification here, since I can’t resist jumping back into my philosophy of mind days.

Supervenience is a thesis in philosophy of mind (actually originated in meta-ethics, but was applied to philosophy of mind) that attempts to address the problem of mental causation: how it is that thoughts ("I feel too cold") end up affecting the physical world (I close the window)? The physicalist camp explains this by saying that all mental phenomena are actually physical, so every mental -> physical causal relation is actually a physical -> physical causal relation.

They often explain this using the concept of supervenience: the mental supervenes on the physical. Meaning that any change in mental state has to have a corresponding change in physical state. If you have a thought, that thought supervenes on a certain configuration of neural impulses. If that thought changes or leads to another thought, there's going to be a corresponding change in neural impulses. However, given the fact that thus far science has failed to produce 1:1 correlations between thoughts and brain states, this has lead to some additional camps in the physicalist field:

1) Emergentists. Emergentists believe that there never will be a 1:1 physical explanation for every mental phenomenon because mental states contain emergent properties that can't be reduced to the physical constituent parts. Think of the software-vs-hardware distinction: software cannot run without hardware, and any computation will have a corresponding change in the electrical impulses on a microchip, but you would be hard-pressed to explain all the properties of software (data structures, iterative processing, etc.) solely in terms of their corresponding electrical impulses. Some valuable information would be lost in that reductionist explanation.

2. Reductionists. Reductionists believe that every mental phenomenon does have a 1:1 counterpart in a physical state. Meaning that the thought "I feel cold" and the specific configuration of neural impulses associated with that thought ("neural state X") can be interchanged with no loss of information or meaning. They believe that given enough time and progress, science will be able to generate that 1:1 dictionary of thoughts and brain states--we're just not there yet right now.

The above would be a reductionist supervenience physicalist perspective.

There's been plenty of ink spilled on whether supervenience physicalism can be non-reductionist without being emergentist, or emergentist without being non-reductionist, or whether it can sidestep this distinction altogether. This entire field is a very interesting can of worms, but it is a can of worms nonetheless.

So, back to the quote:

One of the main criticisms leveraged against the BPS model conceptually (i.e. outside of the harm done to patients) is that it relies on a cartesian dualist perspective of mind-body relationism, in which mental phenomena do not necessarily have physical correlates. This is usually seen as a pretty anti-science view (you'd basically have to claim that the "soul" manifests itself in the body), so the scientists and medical professionals in the BPS camp instead point to developments in philosophy of mind to say "Look! There are explanations of mental phenomena that are physicalist, and therefore complementary to scientific worldviews. We're not bad scientists!"

So this quote is essentially saying "Yes we know that there are criticisms against the BPS model, but those problems are actually due to the incompleteness of physicalist conceptions of the mind-body relation, so they will sort themselves out as soon as philosophy of mind sorts itself out."

Which is, if I'm taking my emotion out of it, a masterful example of academically "passing the buck".

 

I think it is worth battling the BPS camp on their own philosophy-of-mind terms, since it reveals the logical inconsistencies inherent in their actual application of the BPS model and prevents them from hiding behind the academic complexity of philosophy of mind to explain away their faults.

The BPS practitioner sees the supervenience thesis and attempts to translate that to a "pathological" brain state. They will say that a patient's thought ("I feel exhausted") must have a corresponding brain state. Furthermore, since that brain state is physical, it can be causally efficacious--it can affect other parts of the body. This is why it's not necessarily a problem to the BPS worldview to point out that ME/CFS has been tied to various measurements of mitochondrial dysfunction, blunted cortisol, differences in cytokine profiles, etc. etc. etc. None of that actually contradicts their "model".

They can just explain the appearance of physical manifestations in terms of physicalist mental causality. The desire to be seen as sick results in the perception of being sick, which results in physical changes. None of that presents a problem to a physicalist view of the mind-body problem if you say that ALL of those things are actually physical.

But they make a crucial causative mistake: BPS practitioners claim that since a thought can be physically efficacious, physical state is actually downstream of the initial thought, and therefore changing the thought will change the physical state. Their evidence for this comes from the application of CBT to depression, where there is some evidence (albeit still controversial and certainly not universal) that changing thought patterns has a measurable difference in physiological state. The mistake is in thinking that the same causative dynamics are present in any other instance where mental thoughts/perceptions seem to have a physical counterpart. There's even an abhorrent history of trying to apply this logic to cancer patients, out of the belief that cancer is the manifestation of personality flaws.

So sure, we can grant that "mental" phenomena are capable of causing "physical" phenomena, and use whatever toolkits are available in philosophy of mind to describe how that happens. But there's several completely unsubstantiated leaps between that claim and claiming that physical tiredness will disappear if you somehow prevent someone from perceiving it. For the simple fact that the actual causative relation is more likely to be reduced ATP production -> perception of tiredness instead of desire for tiredness -> perception of tiredness -> reduced ATP production.

 

If thoughts can affect any part of the body in any way, then I should be able to make myself turn green without any external interventions.

If you tell me that’s impossible, I challenge you to define what is possible and not.

You should quickly come to the realisation that there are physical limits to what the CNS actually can and can’t make happen.

 

I wouldn't bother @jnmaciuch. I tried it ten years ago and established that the BPS lot don't actually have any idea what they are talking about in this realm so it is a waste of time trying to get on their 'terms'. There aren't any. As you will probably have noticed they constantly accuse others of being Cartesian Interactive Dualists when that is exactly what they are. They haven't even read Descartes.

Interesting that we have so many common interests. You might be interested to read my papers in Journal of Consciousness Studies and Qeios on philosophy of mind. All the stuff about 'physicalism' and 'physical' and 'mental' causes is based on blind alleys in philosophy in the twentieth century that have nothing much to do with science or physics or metaphysics (qua the study of basic concepts underlying physics). All causation is physics because physics is just the study of causation. Leibniz, Locke and Newton knew that but recently people have lost the plot. David Chalmers was very good at popularising PoM but he has never really understood what physical science was about.

 

I take your point here—I think the BPS camp themselves is just dedicated to willful hermeneutical ignorance at this point. By “battling” them I more mean taking down their arguments and de-mystifying the academic language of philosophy of mind in a public forum, so any layman can judge for themselves that theres nothing of substance to their arguments. Otherwise, it’s easy for people to just say “this is all above my head” and tune it out, believing that the people using these high-falutin terms must know what they’re talking about.

I wrote a short thesis on epistemic injustice in the BPS model for ME/CFS in undergrad and some other people at my school ended up reading it because it was nominated for a library award. Ended up having some great one-on-one discussions and winning over some new allies, since those people probably would have just listened to the “experts” if I didn’t lay it out for them.

And thanks for the recs! I always thought the rise of analytical philosophy was very interesting as a sociological phenomenon—an attempt to restructure philosophy to match the hard sciences, which were suddenly eclipsing philosophy as the primary source of intellectual credibility in academic spheres. I think there are a few gems in the field, though. I’m currently making my way through Metzinger to decide what I think of his work since I only read snippets from him in undergrad. Unfortunately I haven’t had time to do much philosophy reading since I started grad school in biomedical research!

 

That’s one we might want to add to a reading list or archive to have to hand for all sorts where it sounds like it can be a useful reference (and save some work on writing certain issues ourselves if they’ve got those issues covered)

 

Is it magpie-ing or cuckoo-ing or maybe both they seem to do to subjects they fancy nicking a one-liner from to twist to their own meaning ?

I agree the bps aren’t interested in learning (they don’t care about it being wrong if it works for them where they need it to) but those in philosophy and particularly philosophy of mind I agree should be taking the opportunity to correct and point out their errors and flaws

1. because they need to look at what not doing so did to those who used real CBT etc and how they cleaned out the professionals to replace with off the shelf delivered by people trained only in cbt of s certain kind rather than eg psychology and ‘what works and what do people have etc’

2. ok there’s a reputation and energy question but they aren’t in the same medical hierarchy so they absolutely can with less risk and would be preserving the reputation of their subject which at the moment is being worse than pop-Phil-Ed by people like this just going round doing their storytelling vs it supposed to have some rigorous thinking techniques behind it

3. it’s actually a pretty important applied area for the future for them to get involved with surely - given the ££$$$$s involved with bps kingdoms and the stuff like Wallits whatever they now call it stuff. No reason why those who can actually do the thinking properly and the logic shouldn’t be the ones regulating and checking on and critiquing the supposed rationales behind said treatment of approaches (where said ‘fund me’ papers from bps are based on pseudo philosophy claims and theory ) - at least they could be correcting them or oversighting it?

pipe dream to one day see some philosopher appear on whichever tv or radio programme after eg suzanne o Sullivan or Sharpe to say ‘well yes you see where they’ve got it round their neck with dualism havent they…’.

…But I can see that playing into the hands of the anti experts type sentiment that has been pushed / grown in the last decade. So probably needs someone speaking in pretty ‘blunt’ terms

 

Having just finished reading that reference (Van Oudenhove & Cuypers, 2014), I don't think it's particularly useful as a critique of psychosomatic medicine for the purposes of ME/CFS patients trying to prevent further harm to ME/CFS patients. Van Oudenhove & Cuypers are not actually arguing that the BPS model is inherently incoherent in terms of philosophy of mind. Rather, they are saying that a failure to explicitly articulate the BPS model in terms of a non-reductionist physicalist perspective will lead to some practitioners inadvertently developing a dualist belief system, which would hamper research in support of the BPS model. They argue that articulating the BPS model in terms of non-reductive supervenience physicalism would fix the problem of "accidental dualism" amongst BPS practitioners. Furthermore, it would result in a coherent conception of mental causation at the heart of the BPS model. That's pretty much the whole scope of the article.

Side note: I think their work creates some confusion as to where emergentism, reductionism, and supervenience physicalism do and do not overlap (though I'd have to go back to my notes to make sure I did not misremember the respective definitions).

"Coherence" as used by Van Oudenhove & Cuypers mostly refers to whether there are internal contradictions in how the model explains mental causation (i.e. talking on both physicalist and dualist terms despite the fact that they are incompatible stances). For what it's worth, I don't think that the BPS model is inherently incoherent in claiming that "mental" and "social" phenomena can effect "physical" state. We already know this is true in certain instances ("I feel cold" --> my hand reaches to close the window). You could create an entirely "coherent" BPS model by articulating it solely in terms of non-reductive physicalism. But importantly, that would not fix the issues of patient harm because the patient harm doesn't stem from latent dualism in the BPS model.

The issue lies, as I and @Utsikt have already pointed out, in a failure to accurately determine the causal relationship between certain thoughts/perceptions and the physical state of the body:

Our critiques of the BPS model are not a "philosophy of mind" problem, but rather a "many disease states simply cannot be reversed by positive thinking" problem. And this community has already written extensively on the issues with using studies like the PACE trial as "evidence" that eliminating "negative perceptions" actually improves physical state. We can even acknowledge that "psychological stress" may have been part of a series of factors leading to ME/CFS in some individuals--our argument is that there's no strong evidence of "stress management" having the power to reverse changes that have already occurred on a cellular or systemic level in ME/CFS.

I think it's worthwhile to stick to those points instead of going to a critique of philosophical incoherence, since it's entirely possible for the BPS model to become "philosophically coherent" (i.e. non-reductive physicalist) without being right about what's driving ME/CFS disease pathology.