The Biopsychosocial Model and Reciprocal Triadic Causation

Full text

60 Computer Systems Experiences of Users with and without Disabilities
BOX 3.1 THE BIOPSYCHOSOCIAL MODEL AND
RECIPROCAL TRIADIC CAUSATION
STEFANO FEDERICI AND FABIO MELONI
The biopsychosocial model of health and individual functioning, pro-
moted by the World Health Organization and endorsed by the International
Classication of Functioning, Disability and Health (ICF; WHO, 2001),
considers disability as the complex and multideterminate outcome of three
main factors: the individual’s health condition, personal factors, and envi-
ronmental factors. The triadic reciprocal causation of these factors has
replaced the etiological perspective of linear development that, from an
altered state of health, leads to disability. In the biopsychosocial model,
disability, understood as both a limitation of an individual’s abilities and a
restriction in social participation, is certainly related to a health condition,
conventionally regarded as pathological; however, it is not necessarily con-
sidered to be caused by the same health status as that in the linear model of
the previous classication of disability published in 1980, the International
Classication of Impairments, Disability and Handicaps, known by the
acronym ICIDH (WHO, 1980). Within the ICIDH, disability (and/or handi-
cap) is the direct result of an impairment of the individual “that limits or
prevents the fullment of a role that is normal (depending on age, sex, and
social and cultural factors) for that individual” (WHO, 1980, p. 29 [italics
in the original].), according to a model based on linear causality and rela-
tions between an independent variable and a dependent one (Federici et al.,
2012b) as shown in this sequence taken from the Introduction of the ICIDH
(WHO, 1980, p. 11):
Diseaseimpairmentdisability handicapÆÆÆ
According to this model, more commonly called the medical/individual
model, disability, and within ICIDH, handicap too—a term that during
the revision process from ICIDH to ICF was abandoned, in response to
the requests from the English-speaking countries that considered the term
handicap to be both stigmatizing and discriminatory (Federici and Meloni,
2010a)—is described as a manifest consequence of a pathological health
condition. As a consequence, the ICIDH’s categories describe different
structural and functional impairments, and different disabilities and handi-
caps resulting from impairment. In contrast, the ICF does not classify dis-
ability as a direct consequence of a disease, but as an individual’s specic,
temporary or permanent, way of “functioning” in a given context. Therefore,
it can be argued that “ICF does not classify people, but describes the situ-
ation of each person within an array of health or health-related domains”
(WHO, 2001, p. 10).

61Why We Should Be Talking about Psychotechnologies for Socialization
The origins of the biopsychosocial model date back to the proposal put for-
ward by psychiatrist George Engel in 1977 for integrating the dominant social
and psychological variables within the medical model:
The dominant model of disease today is biomedical, and it leaves no room
within its framework for the social, psychological, and behavioural dimensions
of illness. A biopsychosocial model is proposed that provides a blueprint for
research, a framework for teaching, and a design for action in the real world of
health care. (Engel, 1977, p. 130)
Engel made the leading theoretical contribution to building the biopsy-
chosocial model, identied in von Bertalanffy’s General Systems Theory
(vonBertalanffy, 1950). According to this approach, the unifying principles
in the scientic context are not understood by a reduction to smaller units;
instead, it is the nature of its organization that explains a scientic phenom-
enon. It is not sufcient to divide a scientic phenomenon into a simpler unit
of analysis and study such units one by one; instead, it is necessary to study the
interrelations among these units.
As a result, human beings are also seen as systems ecologically plunged into
multiple systems (Gray et al., 1969). In the biopsychosocial model, the deni-
tion of the state of health or illness is therefore the outcome of the interaction of
processes that operate at the macro level (e.g., the existence of social support for
depression) and the processes that operate at the micro level (e.g., biological or
biochemical derangements). (Federici et al., 2012b, p. 12)
According to the biopsychosocial model, the factors that affect an individual’s
functioning are interconnected elements of a system (Figure 3.1), which have
properties that are not readily apparent from the properties of the individual
elements (Rydin et al., 2012).
Thus, it is impossible from this perspective to isolate disability from the func-
tioning of an individual and vice versa, or rather hypothesize one without the
other, not only at the level of social organization but also at the level of a single
individual. Disability implies functioning and vice versa. When I. K. Zola in
“Toward the Necessary Universalizing of a Disability Policy” (1989) expresses
hope for the demystication of the “specialness” of disability and the admission
that “people with a disability have long been treated as an oppressed minor-
ity” (p. 19), he assumes a conception of disability that is uid and contextual:
“Disability is not a human attribute that demarks one portion of humanity from
another (as gender does, and race sometimes does); it is an innitely various but
universal feature of the human condition” (Bickenbach et al., 1999, p. 1182). The
issue of disability for individuals “is not whether but when, not so much which
one, but how many and in what combination” (Zola, 1993, p. 18). (Federici etal.,
2012b, p. 12)
Triadic reciprocal causation (Figure 3.1) is a term introduced by Albert
Bandura (1986) to refer to the mutual inuence between three sets offactors.

62 Computer Systems Experiences of Users with and without Disabilities
Applying Bandura’s theory to the biopsychosocial model, the fact that the three
entities (health condition, environmental factors, and personal factors) affect
each other does not mean that they have the same weight (Bandura, 1997).
Not only, then, is the model of a linear causality within the ICIDH superseded
by a transactional model in which the elements are in a reciprocal causation
(the term causation is used herein with the meaning of functional dependence
between events; Bandura, 1997), but the weight that the health conditions (dis-
orders or diseases) can exert on disability may, under certain conditions, be
minimal compared with, for example, the effect of environmental factors:
A problem with performance can result directly from the social environment,
even when the individual has no impairment. For example, an individual who
is HIV-positive without any symptoms or disease, or someone with a genetic
predisposition to a certain disease, may exhibit no impairments or may have
sufcient capacity to work, yet may not do so because of the denial of access to
services, discrimination or stigma. (WHO, 2001, p. 21)
According to the ICF, technologies, when viewed as a systematic process,
method, or an artifact designed to solve problems posed by the environment,
are set within the context of the individual operating components (health con-
dition, environmental factors, personal factors) as facilitators for improving
individual functioning. To the extent, then, that a technology is produced with
the specic goal of assisting a person with disability, it can be dened as an
assistive product or technology (WHO, 2001, p. 164). In this sense, the de-
nition of technology can be traced back to what the philosopher of science
Health condition
(disorder or disease)
Personal
factors
Environmental
factors
FIGURE 3.1 Reciprocal triadic causation between the components of ICF according
to the biopsychosocial model: “There is a dynamic interaction among these entities:
interventions in one entity have the potential to modify one or more of the other enti-
ties.” (From World Health Organization (WHO), International Classication of
Impairments, Disabilities, and Handicaps. A Manual of Classication Relating to the
Consequences of Disease, WHO, Geneva, Switzerland, p. 26.)

63Why We Should Be Talking about Psychotechnologies for Socialization
Bernard Stiegler proposed could be seen in the relation between the human
being and its technology, namely, a phenomenon of epiphylogenesis, a new
relation between the human organism and its environment: lithic technology
and tools are preserved beyond the life of the individual who produced them
and determine the relation of the human being with the environment, thus
conditioning a part of the selection pressure (Stiegler, 1992).
As shown in Figure 3.2, then, the technology itself arises as product that
modies human behavior, in that it determines the relationship with the envi-
ronment (e.g., by placing itself as a facilitator that reduces barriers); it assigns
meaning to the environment (e.g., because it makes the environment accessible
to the human experience and, therefore, usable: a particular stone may begin a
wheel); it expresses meanings about individuals (the introduction of writing, by
changing the way of human communication, gives new meanings to individu-
als who mediate their communication by writing, for example, separating them
into the illiterate and the literate); it is a method of an organism– environment
interaction (a square as a real meeting place and a square as virtual reality,
such as a social network, are two ways of interaction determined by the intro-
duction of two different human technologies); and, nally, it is a behavior (the
use of specic technology requires the acquisition of new skills that produce
culturally determined human behavioral skills: hunting and shing, agricul-
ture, urbanization, etc.).
In these circumstances, it is easy to see how the biopsychosocial model of
human functioning and the transactional theory of reciprocal triadic causation
provide a theoretical framework within which we may include and develop the
denition of psychotechnologies. In fact, technology, by its nature, originated
from the human psyche, but it also determines the relation of the human being
with its environment, and affects part of the selection pressure by modifying
its creator.
Health condition
(disorder or disease)
Personal
factors
Environmental
factors Technology
Technology
Technology
FIGURE 3.2 Reciprocal triadic causation between the components of ICF according
to the biopsychosocial model and the role of the technology.