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The bio-psycho-social model forty years later: a critical review

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Paolo Gritti at University of Campania "Luigi Vanvitelli"
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Abstract

Since 1997, the Bio-Psycho-Social Model, proposed by George Engel, attracted the interest of clinical researchers as well epistemologists and was recognized as a turning point in the culture and praxis of medical diagnosis and treatments. According to Engel, biological, psychological as well as social events are mutually interconnected and reciprocally influenced; a paradigmatic shift in the approach to the mind-body problem. Lately, this model has received persuasive criticism that has caused a fading of its scientific reliability. This concise review focuses the core feature of Engel‟s position as well as the scientific controversy that followed during these forty years.
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JPS, 2017, Vol. 1(1), pp. 36 - 41 Section: MINI REVIEW
Doi: 10.23823/jps.vlil.14
Gritti
The bio-psycho-social model forty years later: a critical review
Paolo Gritti*
*Università degli Studi della Campania “Luigi Vanvitelli”
Abstract
Since 1997, the Bio-Psycho-Social Model, proposed by George Engel,
attracted the interest of clinical researchers as well epistemologists and was
recognized as a turning point in the culture and praxis of medical diagnosis and
treatments. According to Engel, biological, psychological as well as social events
are mutually interconnected and reciprocally influenced; a paradigmatic shift in
the approach to the mind-body problem. Lately, this model has received
persuasive criticism that has caused a fading of its scientific reliability. This
concise review focuses the core feature of Engel‟s position as well as the scientific
controversy that followed during these forty years.
Introduction
Forty years ago a novel vision on health and disease emerged in the field of
biomedicine. The Bio-Psycho-Social Model, proposed by George Engel, an
American internist trained in psychoanalysis, was recognized as a turning point
in the culture and praxis of medical diagnosis and treatments. Actually, until the
first half of „900, the western medicine had been influenced by the Cartesian
dichotomy between body and mind, but this philosophical premise was about to
change. Immediately after the II World War, Ludwig von Bertalanffy, an Austrian
biologist, proposed his scientific view on open systems, then included in the
General System Theory (GST) (1968). The GST attempts to build a bridge between
natural sciences and humanities by means of a holistic approach to scientific
knowledge. About thirty years later, George Engel borrowed GST as an
epistemological template in order to support his theoretical construct. This
concise and selective review is focused on the core feature of Engel‟s BPSM as
well as the scientific controversy that followed during the next forty years.
The essence of the BPSM
In 1997 George Engel published his seminal paper focused on the need for a
holistic approach to health and disease, namely the Bio-Psycho-Social Model
(BPSM). He borrowed the GST by Ludwig von Bertalanffy launching an intriguing
hypothesis that gained a wide diffusion in the fields of biomedicine, psychology
and social sciences (Suls & Rothman, 2004): biological, psychological as well as
social events are mutually interconnected and reciprocally influenced. Engel
moved from his thesis about a crisis of medicine descending from the”adherence
to a model of disease no longer adequate for the scientific tasks and social
responsibilities of either medicine or psychiatry”. Engel argued that the biomedical
model, assuming that diseases have only biological causes, hence consistent with
a reductionist and physicalistic principle, is a culturally derived belief system
JPS, 2017, Vol. 1(1), pp. 36 - 41 Section: MINI REVIEW
Doi: 10.23823/jps.vlil.14
Gritti
“utilized to explain natural phenomena”. Engel asserted that the biomedical model
is far from being a scientific model because it fails to account adequately for all
the data, namely the psychosocial concurrent variables of the diseases. Such a
model, excluding psychosocial issues, determines a harmful separation of
medicine, psychiatry, and psychology, even though these three disciplines are
equally devoted to the treatment of diseases.
The most intriguing issue embedded in the BPSM is the direction of causation
between biological and psychosocial phenomena: Engel, according to von
Bertallanfy view, assumed that the causal connections between the bio-psycho-
social domains should be intended as bidirectional, so there is no primacy of the
biological domain over psychosocial domains and vice versa. This epistemological
shift is more clear in the 1980 paper: from subatomic particles to the biosphere,
each systemic level is part of a whole entity (Engel, 1980). Engel wrote: “In the
continuity of natural systems every unit is, at the very same time, both a whole and
a part”. In Engel‟s view as “nothing exists in isolation”, every system is influenced
by its environment. Consequently, a so-called “system-oriented scientist” should
be always aware of the connecting pattern that bonds the biological phenomena
to the psychosocial ones. The case of “Mr. Glover” (Engel, 1980), a 55-year old
male who developed an arrhythmia following a myocardial infarction and hence
brought to an emergency department, is described to outline the model. The
myocardial ischemia of Mr. Glover is intended as the end of a multidimensional
process involving, at the same time, his body, his relational network, and the
doctor-patient relationship. In a later paper, Engel (1997) alleges the humanistic
nature of BPSM as well as its disposition to the patient‟s inner experience. This
radical causal hypothesis is fully divergent from the orientation of biomedicine in
the last decades: the BPSM implies that psychosocial events can have an effect
on the biological ones. The Engel‟s position is, therefore, a paradigmatic change
in the „900-century approach to the mind-body problem. The wide appeal of
BPSM was, in my opinion, inherent to a socio-cultural movement that pervaded
the western world at the end of the century. The postmodern vision of social
phenomena, expressed by Bauman (2000) with his metaphor of a “liquid” society,
disputes a linear and deterministic knowledge of the world. Moreover, the so-
called “post-truth medicine” challenges the evidence-based one. However, forty
years later the above mentioned Cartesian approach to the etiopathogenetic
processes is still predominant, supported by an extensive amount of scientific
literature. According to Evans at al (2017), ”the most enduring model of disease
causation and progression is the pathological model”. This model describes the
sequential progression of a disease assuming that only biological factors
contribute to the pathology. Therefore, the model is linear because the disease
progression occurs only in an upward direction, from the body to mind. This is
the limit of the pathological model: psychological factors are considered as
epiphenomena of biological processes, or, at least, concurrent variables of
primitive somatic diseases. On the contrary, the BPSM highlights that the range
of causes, as well as the intervention options, should include psychological and
social domains. As regards the philosophical roots of the BPSM, Evans (2017)
argues that it dates back to a sort of ”Biopsychosocial dispositionalism” which
describes causal pathways embracing the psychosocial variables.
JPS, 2017, Vol. 1(1), pp. 36 - 41 Section: MINI REVIEW
Doi: 10.23823/jps.vlil.14
Gritti
The debate on BPS model
Since the ‟80s, the BPSM attracted the interest of clinical researchers as
well epistemologists (Frankel, Quill & McDaniel, 2003) (White,2005). These last
ones formulated a number of intriguing criticisms to the biopsychosocial
approach to health and disease. Fist of all, BPSM may be described as a
“portmanteau model “(Baruch & Treacher, 1978), a “form of inclusive compromise”
(Pilgrim, 2002) or, in my own words, an “ecumenical model” aimed at gathering
the healing resources of biology, psychology, and social sciences. Moreover, since
the turn of the century, this model has drawn other persuasive criticisms that
caused a fading of its scientific reliability. The reason for this decline, according
to Shorter (2005), was the great advance of drug therapies: “the biopsychosocial
model failed to address the stunning success of pharmacotherapy in the last
quarter century. Engel had the misfortune to be preaching a humane approach to
patients just as the pharmacopoeia was exploding with effective new drugs in a
range of diseases in all of the non-surgical specialities.”. Other critics highlighted
more cogent arguments. McLaren (1998), examining the Engel‟s proposal,
suggests keeping in mind the differences between theories and models. As a
model, the BPS approach should be evaluated by the mean of its assessable
effects in the clinical field rather than its heuristic potentiality. Moreover,
McLaren contends the legacy of GST in the Engel‟s model. GST describes the laws
of natural systems rather than the causes of pathological processes. Pilgrim
(2002) states that a pluralistic and interdisciplinary orientation of psychiatry does
not descend from the BPSM, but rather from the pragmatism of modern
psychiatrists. The BPSM only engendered an “interdisciplinary cooperation”. Thus,
Pilgrim rewards Engel of a strong integrative thinking in the field of behavioral
sciences. Borrell-Carrió et al (2004), while defending the Engel‟s position,
consider the value of the biopsychosocial model not in term of a new scientific
paradigm, but rather in a methodological warning concerning a “parsimonious
application of medical knowledge to the needs of each patient”. Borrel-Carrio, in
order to improve the feasibility of the BPSM, highlights three critical aspects.
First, the investigation of the relationship between mental and physical aspects of
health should consider that the subjective experience is not only owing to the
laws of physiology; Second, the circular causality principle should be confronted
with a linear reasoning when considering treatment options; Third, a patient-
oriented approach to the illnesses may not be universally accepted. Borrel–Carrio
suggests a biopsychosocial-oriented clinical practice grounded on a subjectivity
principle, supported by self-awareness, an emotional style characterized by
empathic curiosity, a self-calibration as a way to reduce bias and a confidence in
the emotions to assist with diagnosis and forming therapeutic relationships.
Moreover, Borrel-Carrio trusts in informed intuition and in openness to
communicate all clinical evidence to foster a dialogue with the patient not merely
guided by mechanical application of a protocol. Ghaemi (2009) is recognized as a
persuasive critic of Engel‟s ideas. He ascribes to the BPSM a weak and eclectic
epistemology, a defensive strategy against a biomedical reductionism and an anti-
humanistic position. Moreover, Ghaemi argues that the “eclectic freedom” of BPS
epistemology risks “to engender an undisciplined, even arbitrary approach: „one
can emphasize the „bio‟ if one wishes, or the „psycho‟ … or the „social‟.” Kontos
(2011), affirms that “biopsychosocial advocates use clinical biomedicine as a straw
JPS, 2017, Vol. 1(1), pp. 36 - 41 Section: MINI REVIEW
Doi: 10.23823/jps.vlil.14
Gritti
man to support their argument” however, the “biomedical dogma” is not the
primary impediment to the BPSM dissemination within the medical practices but
rather its unmanageability. Kontos concedes that the BPSM “shares many of the
potential pitfalls that it attributes to clinical biomedicine” and concludes that the
complexity of contemporary medicine must be supported by different scientific
models. Adler (2009), shares this opinion: the biomedical model and the BPSM
are not mutually exclusive. Smith et al. (2013), evaluated the BPSM feasibility in
order to implement the patient-centered practices. They pointed out three
criticisms of the BPSM. First, it is not testable. It is vaguely defined and not
operationalized in behavioral terms for the patient. Furthermore, the BPSM is too
general and eclectic, requiring a wide amount of time-consuming information
about the patient, and not applicable in the routine clinical practice. Finally, the
BPSM is methodologically weak because it does not provide any operational
recommendation about the process of exploring the bio-psycho-social dimensions
of the disease. Hence, BPSM cannot be tested and should be only conceived as a
general theory or simply a pre-scientific or meta-psychological rationale for the
mind-body connection. Benning (2015) remarks that has been a growing body of
literature criticizing the BPSM, by “charging it with lacking philosophical
coherence, insensitivity to patients‟ subjective experience, being unfaithful to the
general systems theory that Engel claimed it be rooted in, and engendering an
undisciplined eclecticism that provides no safeguards against either the dominance
or the under-representation of any one of the three domains of bio, psycho, or
social.”. In summary, some prominent authors expressed cogent criticism to the
BPSM in recent years. Thus, in light of these viewpoints, the BPSM seems to be
almost as useful in the field of psychiatric diseases at the price of splitting the
psychosocial approach from the neo-Kraepelinian and neurobiological trend of
psychiatry (Brenner 2016). Moreover, the BPSM does not improve the research
about the multidimensional causative process leading to the diseases, but only
suggests a comprehensive clinical approach to the patient. Therefore, this goal
should be achieved by implementing the BPSM by mean of working techniques of
the interview.
The BPSM credit among health professionals: a focus group
Which will be the future of BPSM in the next decades? It will depend, in my
foresight, upon how much credit it will gain from young health professionals.
These colleagues are, more frequently, educated according to a linear approach to
the patients‟ illnesses. A simple, preliminary investigation on this topic was
conducted to explore the attitudes toward the bio-psychosocial model of a small
sample of young Italian psycho-oncologists. These professionals were selected
because their peculiar field of intervention, namely the application of
psychosocial skills in the cancer treatments, is frequently oriented by the BPSM,
according to an integrated approach the treatments of these illnesses (Holland,
2001). Moreover, this model is well known by leading Italian psycho-oncologists
as a conceptual framework in their clinical contexts. So, ten psycho-oncologists
who were about to achieve a postgraduate master‟s degree in psycho-oncology
were asked to read and discuss the Engel‟s papers during a journal club session
(Ebbert, 2001). They should point out the strong and weak points of the model. At
the end of the session, the shared opinions of this group were expressed as
JPS, 2017, Vol. 1(1), pp. 36 - 41 Section: MINI REVIEW
Doi: 10.23823/jps.vlil.14
Gritti
follows.The BPSM was evaluated as too much generic in its theoretical framework
and scarcely useful in clinical practice. All participants agreed about the heuristic
implication of the model, but suggested to improve it by specific interview
protocols.
References
[1] Adler R.H., (2009), Engel's biopsychosocial model is still relevant
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[2] Bauman Z., (2000), Liquid Modernity, Blackwell Publishers, UK
[3] Baruch G. & Treacher A., (1978), Psychiatry Observed, London:
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[4] Benning T. B., (2015), Limitations of the biopsychosocial model in
psychiatry, Advances in Medical Education and practice, 6: 347-352
[5] Borrell-Carrió F., Suchman A. L.,Epstein R. M., (2004), The
Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific
Inquiry, Ann Fam Med, 2 (6): 576-582
[6] Brenner A. M., (2106), Revisiting the Biopsychosocial Formulation:
Neuroscience, Social Science, and the Patient‟s Subjective Experience, Acad
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[8] Engel G. L., (1977), The need for a new medical model: a challenge for
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[10] Engel G. L., (1997), From biomedical to biopsychosocial: being
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Objective: To review the scientific status of the biopsychosocial (BPS) model and to propose a way to improve it. Discussion: Engel's BPS model added patients' psychological and social health concerns to the highly successful biomedical model. He proposed that the BPS model could make medicine more scientific, but its use in education, clinical care, and, especially, research remains minimal. Many aver correctly that the present model cannot be defined in a consistent way for the individual patient, making it untestable and non-scientific. This stems from not obtaining relevant BPS data systematically, where one interviewer obtains the same information another would. Recent research by two of the authors has produced similar patient-centered interviewing methods that are repeatable and elicit just the relevant patient information needed to define the model at each visit. We propose that the field adopt these evidence-based methods as the standard for identifying the BPS model. Conclusion: Identifying a scientific BPS model in each patient with an agreed-upon, evidence-based patient-centered interviewing method can produce a quantum leap ahead in both research and teaching. Practice implications: A scientific BPS model can give us more confidence in being humanistic. In research, we can conduct more rigorous studies to inform better practices.
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The biopsychosocial model in Anglo-American psychiatry: Past, present and future?
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  • Jan 2002
The biopsychosocial model in Anglo-American psychiatry is appraised. Its content and history are described and its scientific and ethical strengths noted. It is situated in relation to competing approaches in the profession, especially an older but enduring biomedical model. The tensions provoked by the latter, in relation to 'anti-psychiatry', the users' movement and 'critical psychiatry' are explored, as a context in which the biopsychosocial model has both emerged and been constrained. At the end of the paper, reasons for the relative lack of success of the model are discussed and its future prospects assessed.
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Engel's biopsychosocial model is still relevant today
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Full-text available
  • Dec 2009
In 1977, Engel published the seminal paper, "The Need for a New Medical Model: A Challenge for Biomedicine" [Science 196 (1977) 129-136]. He featured a biopsychosocial (BPS) model based on systems theory and on the hierarchical organization of organisms. In this essay, the model is extended by the introduction of semiotics and constructivism. Semiotics provides the language which allows to describe the relationships between the individual and his environment. Constructivism explains how an organism perceives his environment. The impact of the BPS model on research, medical education, and application in the practice of medicine is discussed.
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Biopsychosocial Medicine: An integrated approach to understanding illness
Article
  • Apr 2005
The biopsychosocial model is an approach to medicine which stresses the importance of a holistic approach. It considers factors outside the biological process of illness when trying to understand health and disease. In this approach, a person’s social context and psychological well-being are key factors in their illness and recovery, along with their thoughts, beliefs and emotions. This title examines the concept and the utility of this approach from its history to its application, and from its philosophical underpinnings to the barriers to its implementation. It is severely critical of the failure of modern medicine to treat the patient not the disease, and its neglect of psychological and social factors in the treatment of the ill. Focusing on chronic disabling ill health, this title takes the examples of arthritis, cancer, diabetes, lower back pain, irritable bowel syndrome and depression to show how the biopsychosocial model can be used in practice. It questions why, even when the biopsychosocial approach has been proved to be more effective than traditional methods in overcoming these disorders, is not more routinely used, and how barriers to its implementation can be overcome.
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Biomedicine-Menace or Straw Man? Reexamining the Biopsychosocial Argument
Article
  • Feb 2011
More than 30 years after its introduction by George Engel, the biopsychosocial model exerts a major influence on the rhetoric and intentions of academic medicine. However, advocates of the model do not feel that it has significantly altered the practice of physicians, whom they portray as tightly clinging to a biomedical approach. Using Engel's original writings, those of his successors, and the work of medical historians, the author asserts that biopsychosocial advocates use clinical biomedicine as a straw man to support their argument. Proceeding from that point, the author attempts to demonstrate that excessive focus on this straw man has inhibited critique of the biopsychosocial model and the argument supporting it. He identifies failures to address clinical medicine's functional specificity and relationship with broader social trends as contributors to the biopsychosocial model's stagnation. The author proposes that it would be more productive to view clinical biomedicine as an epiphenomenon of the human traits of overenthusiasm and the need for security. Recognizing that medicine is made up of heterogeneous tasks, he observes that no one model, including the biopsychosocial model, tends to all of them. The biopsychosocial model would be best served by shedding the biomedical straw man and modifying its ambitions.
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