ArticleLiterature Review

The Clinical Application of the Biopsychosocial Model in Mental Health A Research Critique

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Abstract

Engel applied the term biopsychosocial to medicine to emphasize the need to take into account the psychologic and social aspects of medical practice. After an overview of the history of the biopsychosocial (BPS) model, we review criticisms of the model to reformulate its deficiencies and then analyze its application in mental health care. The objectives of this paper are 4-fold: (1) to examine the use of the BPS model since Engel's 1977 article to the present; (2) to examine the reasons for the popularity of the BPS model as well as the problems it faces when applied to mental health care; (3) to introduce two instruments, the International Classification of Functioning, Disability, and Health and the INTERMED, which implement the BPS model; and (4) to show why the BPS model is not yet a model of mental health practice. A total of 62 publications were retrieved and reviewed in the ScienceDirect, PubMed, and Scopus databases, and 32 of them were eventually included in this review. This is the first review of the studies published that applied the BPS model in mental health in the last 33 yrs. These criticisms are used to construct a more workable vision of the BPS model of clinical practice.

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... "Biological" approach is based on physiological and endocrinological responses, while "psychosocial" approach includes stimulus and transactional concepts (11)(12)(13)(14). Biopsychosocial model (BPS), on the other hand, presented as a frame which unifies these two headings (15)(16)(17)(18)(19). ...
... Later, it was defined as unqualified as a model and criticized for limitations such as being non-testable, being too general and not having well defined operational criteria for individual patients (19,31,32). The studies, in which the model was used, indicated the limitations of the model, but it was also emphasized that social, biological and psychological factors were interacted for the analysis of diseases (28,33,34), and similarly results were revealed on how these factors affected physical health altogether (15,25). Currently, the model is considered a more valid approach compared with the past (35)(36)(37), and as the best way of explaining stress (38). ...
... Moreover, it was also indicated that cognitive processes must be included (9,48), and that the best measurement should cover all components such as the BPS model (7,38). The model itself, is presented as novel framework to unite all efforts to explain stress (15,17,19). ...
Article
Introduction: Due to the absence of Turkish psychometric devices assessing stress, in the present study it was aimed to develop a stress scale, and examine its basic psychometric properties. Methods: Current study included two processes, formation of item pool and examination of psychometric properties of the selected items through three studies. In the first study, 611 individuals aged between 18 and 77 responded to 130 selected items. In the second study, 2223 individuals aged between 18 and 68 responded to 80 items. In the third study, 1969 individuals aged between 18 and 79 responded to the final form of 36 items. Further, in study 3 for criterion related validity 163 individuals completed the Coopersmith Self-Esteem Inventory, 113 individuals completed the Beck Anxiety Inventory, 104 individuals completed the Hospital Anxiety and Depression Scale, 107 individuals completed the Beck Depression Inventory, and 265 individuals completed the Perceived Stress Scale. Moreover, in the investigation of test-retest reliability, 119 individuals took the final form of the test after 2 weeks, and 111 individuals took the final form of the test after 3 weeks. Results: In the first study, out of 130 items, 54 that showed item-total score correlations below 0.30 were excluded from the scale. Fifty-seven items were preserved exactly, and 19 items' sentence structures were changed. Furthermore, by adding 4 new items, 80 were prepared for the second study. In the second study, two factors structure namely "Physiological Reactions/Strain" and "Psychological/Cognitive Appraisals" sub-dimensions were identified, and 36 items were selected via Item Response Theory representing these sub-dimensions. In study 3, exploratory factor analysis provided strong support for our hypothesized two factors structure. Confirmatory factor analysis indicated hypothesized model had a better fit to the data. Internal consistency coefficients were 0.94 for the entire scale, 0.90 for Physiological Reactions/Strain sub-dimension, and 0.91 for Psychological/Cognitive Appraisals sub-dimension. Correlation coefficients between the entire scale and other criterion scales ranged from 0.22 to 0.63. Test-retest correlation coefficients between the first administration of the scale, and the administrations at two and three week intervals were 0.88. Conclusion: Results showed that the scale has basic psychometric requirements provided that the scale will be supported by validity studies.
... Five critiques have been levelled against the BPS approach. Methodologically, some focus on the apparent lack in empirical evidence (Alvarez et al., 2012), agreed criteria to measure each factor, and "testability" (Farre and Rapley, 2017). Practically, some highlight the difficulty of implementing BPS in clinical practice (Alvarez et al., 2012;Benning, 2015), particularly as it is so general (Farre and Rapley, 2017). ...
... Methodologically, some focus on the apparent lack in empirical evidence (Alvarez et al., 2012), agreed criteria to measure each factor, and "testability" (Farre and Rapley, 2017). Practically, some highlight the difficulty of implementing BPS in clinical practice (Alvarez et al., 2012;Benning, 2015), particularly as it is so general (Farre and Rapley, 2017). Culturally BPS is criticised for failing to take account of subjectivity in constructs of the psychological and social factors (Benning, 2015). ...
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Article
Purpose This paper proposes a biopsychosocial (BPS) analysis of COVID-19 experiences which enhances understanding of complex and interrelated factors and leads to the proposition of a BPS recovery framework. Design/methodology/approach Online narrative research was used to explore people's experiences of COVID-19 and was conducted over a four-month period. The call was distributed via a short open-ended qualitative online survey advertised on social media platforms and 305 responses came from across England. Findings The findings illustrate people with a narrow range of BPS characteristics experienced over a wide range of BPS impacts which are nuanced, complex and dynamic. Left unaddressed these may create future adverse BPS characteristics. An integrated BPS framework for recovery is proposed to avoid such further negative outcomes from the pandemic. Research limitations/implications The sample contained a bias in age, gender and living arrangements. Practical implications The paper offers a clear framework to enable integrated holistic recovery/regrowth planning. Social implications Using the framework would reduce social and health inequities which have been recently deepened by COVID-19 in the long-term. Originality/value The paper is original in its use of a BPS analytical framework.
... Besides engaging in a multitude of new tasks during intervention delivery, professionals was also asked to engage in a range of integration activities. To support a bio-psycho-social framework [108], the IBBIS interventions introduced four integration activities: 1) minimum one roundtable meeting at which the service user, the employment consultant, and the care manager finalized an interdisciplinary assessment and decided on a shared plan for return to employment and the required measures of support from the IBBIS team; ...
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Thesis
Evaluation of an integrated intervention in context - A novel collaboration between Danish mental health care services and Jobcenters to improve services for persons on sick leave due to common mental disorders
... 21 It forms the foundation of two measures of case complexity, the INTERMED 22 and the Oxford Case Complexity Assessment Measure (OCCAM). 23 It is probably the most widely mentioned and used model in research into rehabilitation and disability including chronic pain, psychiatric disorders, 24 and, possibly, functional disorders. ...
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Article
The biopsychosocial model outlined in Engel’s classic Science paper four decades ago emerged from dissatisfaction with the biomedical model of illness, which remains the dominant healthcare model. Engel’s call to arms for a biopsychosocial model has been taken up in several healthcare fields, but it has not been accepted in the more economically dominant and politically powerful acute medical and surgical domains.
... This model was introduced by G. Engel in an attempt to move from a reductionistic bio medical approach to include also psycho logical and social dimensions 15 . The model has important strengths insofar as it takes a systemsbased approach that considers a broad range of variables influencing dis ease onset and course, and attends to both the relevant biomedical disease and the patient's experience of illness 16 . ...
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Article
Psychiatry has always been characterized by a range of different models of and approaches to mental disorder, which have sometimes brought progress in clinical practice, but have often also been accompanied by critique from within and without the field. Psychiatric nosology has been a particular focus of debate in recent decades; successive editions of the DSM and ICD have strongly influenced both psychiatric practice and research, but have also led to assertions that psychiatry is in crisis, and to advocacy for entirely new paradigms for diagnosis and assessment. When thinking about etiology, many researchers currently refer to a biopsychosocial model, but this approach has received significant critique, being considered by some observers overly eclectic and vague. Despite the development of a range of evidence‐based pharmacotherapies and psychotherapies, current evidence points to both a treatment gap and a research‐practice gap in mental health. In this paper, after considering current clinical practice, we discuss some proposed novel perspectives that have recently achieved particular prominence and may significantly impact psychiatric practice and research in the future: clinical neuroscience and personalized pharmacotherapy; novel statistical approaches to psychiatric nosology, assessment and research; deinstitutionalization and community mental health care; the scale‐up of evidence‐based psychotherapy; digital phenotyping and digital therapies; and global mental health and task‐sharing approaches. We consider the extent to which proposed transitions from current practices to novel approaches reflect hype or hope. Our review indicates that each of the novel perspectives contributes important insights that allow hope for the future, but also that each provides only a partial view, and that any promise of a paradigm shift for the field is not well grounded. We conclude that there have been crucial advances in psychiatric diagnosis and treatment in recent decades; that, despite this important progress, there is considerable need for further improvements in assessment and intervention; and that such improvements will likely not be achieved by any specific paradigm shifts in psychiatric practice and research, but rather by incremental progress and iterative integration.
... Specifically, the biopsychosocial model promotes consideration of the dynamic interaction between physical health, emotional well-being, and relationship functioning (Engel, 1980). According to this model, all three levels (i.e., biological, psychological, social) must be considered in every phase of care, because they are all integral and interactively related to health and illness (Alvarez et al., 2012;Sadler & Hulgus, 1990). Nonetheless, large-scale research specific to the biopsychosocial impact of sexual violence remains limited. ...
Article
Although it is well-established that sexual assault results in variable and long-lasting negative impacts on emotional well-being, perceptions of physical health, and relationship functioning, these “psychosocial” outcomes may vary based on the type(s) of sexual trauma experienced. To identify the differential impact of sexual trauma type(s) on psychosocial outcomes among veterans and non-veterans, we conducted a secondary analysis of data from the Comparative Health Assessment Interview Research Study, a large, national survey study sponsored by the Department of Veterans Affairs. Participants included veterans ( n = 3588) and non-veterans ( n = 935) who endorsed experiencing childhood sexual assault (CSA), adult sexual assault (ASA, outside of military service for veteran participants), and/or military sexual assault (MSA). Eight measures were used to assess psychosocial outcomes: Well-Being Inventory (WBI) health satisfaction and physical health functioning items, Posttraumatic Stress Disorder Checklist, Patient Health Questionnaire (depression symptoms), Generalized Anxiety Disorder Questionnaire, WBI social satisfaction items, WBI social functioning items, and the Multidimensional Scale of Perceived Social Support (social). A profile analysis was used to determine how sexual trauma type(s) influenced the pattern of responding to the eight psychosocial outcome measures. Veteran sexual assault survivors reported poorer psychological outcomes compared to non-veteran sexual assault survivors. Non-veteran sexual assault survivors reported poorer outcomes on the majority of social variables compared to veteran sexual assault survivors. Survivors of MSA-only reported poorer psychosocial outcomes compared to veteran and non-veteran survivors of CSA-only and ASA-only on most of the variables assessed. Survivors of ASA-only reported similar or modestly worse psychosocial outcomes when compared to survivors of CSA-only on the majority of variables assessed. Survivors of different types of sexual trauma reported distinct psychosocial outcomes, suggesting that assessment and treatment needs may differ by trauma type.
... 5 Future studies could investigate more specifically how mental health professionals in Brazil navigate the possible tensions between a social medicine approach to health and illness and the use of mental health diagnostic categories. One possible practical implication of this finding would be that of working towards an improved integration of both biomedical and psychosocial perspectives within national clinical guidelines, as per the biopsychosocial model [41]. This would ensure that patients experiencing PTSD symptoms in similar high-violence contexts receive appropriate care at the individual level while simultaneously recognising the social-political nature of the roots of their suffering. ...
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Article
Background Adolescents in low-resource urban settings in Brazil are often exposed to high levels of trauma that can result in post-traumatic stress disorder (PTSD). However, preliminary evidence indicates that PTSD tends to be under-reported in Brazilian health services, despite the high prevalence of trauma. Additionally, little is known about the perceived applicability among clinicians of the new ICD-11 diagnosis of complex PTSD (CPTSD), despite its potential relevance for contexts of chronic trauma. The current study investigated local understandings of PTSD and CPTSD among health professionals working with adolescents in violent neighbourhoods of São Paulo city. Methods Semi-structured interviews were conducted with 58 health professionals working at both the primary care and specialized mental health levels in two areas of São Paulo city with high levels of community violence. Results Most participants knew about PTSD, but most did not know about CPTSD. There were mixed views concerning the commonality of PTSD among adolescents exposed to community violence. Many participants reported having no experience working with patients with the PTSD diagnosis. According to some, community violence was normalized by adolescents and health professionals, and did not result in PTSD. Others highlighted how they did not use psychiatric diagnoses in their practice, had critical perspectives towards psychiatric diagnoses and/or PTSD, or simply knew little about PTSD. Furthermore, many highlighted how the chronic nature of multiple traumas experienced by adolescents often resulted in complex clinical presentations characterised by many symptoms beyond PTSD. The diagnosis of CPTSD was considered appropriate to the context by many participants as it captured the complex traumatic histories and symptom presentations of adolescents exposed to community violence in Brazil. Conclusions These findings have important implications for the assessment and treatment of mental health among adolescents exposed to community violence in Brazil.
... Participants perceived difficulty coherently integrating trauma-focused interventions into the clinical discourse of services for psychosis: explanations for this included the dominance of a bio-medical model of illness, understanding of psychological therapies, and clinician characteristics. While the tensions in the implementation of the biopsychosocial model have been discussed extensively elsewhere (Alvarez et al., 2012;Papadimitriou, 2017), this study is the first to explore this tension in relation to the delivery of trauma-focused interventions for people with psychosis, and was not a barrier identified in the treatment of people with PTSD without comorbid psychosis (Finch et al., 2020). These perceived difficulties coherently integrating clinical discourses of psychosis and trauma may offer possible explanations of previous findings that clinician knowledge about trauma in this population was not predictive of clinical practice (Salyers et al., 2004). ...
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Article
Objectives: Trauma-focused interventions have been shown to be effective treatments for post-traumatic stress disorder (PTSD), and clinical guidelines support their use with people with psychosis. Despite this, they are used relatively infrequently in this population. We sought to explore UK health care professionals' perceptions of what impedes or facilitates the use of trauma-focused interventions among people with psychosis and PTSD. Design: A qualitative study using constructivist grounded theory methodology. Methods: We conducted semi-structured interviews with 18 health care professionals working within the commissioning and delivery of clinical services for people with psychosis. Results: Three inter-related barriers to the use of trauma-focused interventions were conceptualized: coherent understanding; structural support; and safe space. Conclusions: Delivery of trauma-focused interventions within routine clinical practice may be supported by attention to the coherent integration of discussion of trauma into the clinical discourse of services; the processes, pathways, and organizational culture that facilitate access to treatment; and training that targets clinician confidence and skills.
... One of the most common critiques of the biopsychosocial model is that, despite Engel's ambitions, it is not a scientific model at all. An important theme among these critiques is that the model is too vague to be testable (Álvarez et al., 2012;Epstein & Borrell-Carrió, 2005;Farre & Rapley, 2017;McLaren, 1998;Smith et al., 2013) because it does not "specify variables or specific relations among the components, and does not contain the elements necessary to make specific testable hypotheses" (B. L. B. L. Wood, 2012). ...
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Article
The biopsychosocial model is among the most influential frameworks for human-centered health improvement but has faced significant criticism– both conceptual and pragmatic. This paper extends and fundamentally re-structures the biopsychosocial model by combining it with sociotechnical systems theory. The resulting biopsychosociotechnical model addresses key critiques of the biopsychosocial model, providing a more “practical theory” for human-centered health improvement. It depicts the determinants of health as complex adaptive system of systems; includes the the artificial world (technology); and provides a roadmap for systems improvement by: differentiating between “health status” and “health and needs assessment”, [promoting problem framing]; explaining health as an emergent property of the biopsychosociotechnical context [imposing a systems orientation]; focusing on “interventions” vs. “treatments” to modify the biopsychosociotechnical determinants of health, [expanding the solution space]; calling for a participatory design process [supporting systems awareness and goal-orientation]; and including intervention management to support the full lifecycle of health improvement.
... It is generally accepted that health and illness are the result of an interaction between biological, psychological and social factors. [4][5][6] In addition, the BPSM is closely tied to the relationship-centred approach involving healthcare professionals taking the patients' perspective, being emphatic and building trust, and being sensitive to patients' and families' psychological needs in order to provide high-quality patient care. [7][8][9] Hence, an important consequence of the BPSM is that the relationship between healthcare professionals and patients influences the patients' health through the support for and satisfaction of the patients' psychological needs. ...
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Article
Objectives: Self-Determination Theory posits that managers' autonomy-supportive behavior and employees' autonomy causality orientation, are motivation constructs to explain internalization of values, functioning, and wellness at work. Hypothesis 1 tested whether profiles comprising perceived dental clinic managers' autonomy-supportive, as opposed to their controlling interpersonal style, and dental hygienists' autonomy, as opposed to their control and impersonal, causality orientations at baseline, would be positively related to dental hygienists' biopsychosocial (BPS) beliefs and giving autonomy support in treatment of patients after 18 months. Hypothesis 2 tested whether dental hygienists' BPS beliefs in treatment of patients will be positively associated with their autonomy-supportive behavior given to patients after 18 months. Material and methods: A prospective cohort design with 299 (Mage = 42.71; SDage = 12.62) dental hygienists completed an online survey at baseline and after 18 months. Results: Latent profile and correlational analyses supported the hypotheses. Effect sizes were moderate to large. Conclusions: Both perceived managerial styles and dental hygienists' causality orientations are important for dental hygienists' BPS beliefs and autonomy-supportive behaviors when working with dental patients.
... The factors I coded were based on Engel's BPS model (1977). Prior to this study, that model had been cited to be best used by researchers who want to develop their own understanding of some of the factors that can impact mental health (Álvarez, Pagani and Meucci, 2012). ...
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Research
Abstract: Context and Rationale: Research into mental ill health has been on the rise in recent years. Academics have strongly associated it to COVID-19. Factors such as – social isolation and loneliness, have often been cited as increasing since the pandemic. However, mental ill health research has been on rise prior to the pandemic as well. The probability of children experiencing mental ill health has increased from 1999 to 2017. Furthermore, depression-like symptoms have increased in adults in recent years too. Due to the current pandemic, it has provided an opportunity for this research to explore how COVID-19 is impacting individual’s mental health, within an educational setting. Currently, research exploring factors that underpin mental health have not been studied in much detail during the pandemic. This case study project therefore aims to identify the impact the pandemic is having on individual’s mental health, so other academics can either use the factors identified in this study to support their own work or to refute them. Research Questions: 1. To what extent has COVID-19 impacted upon children’s and parent’s mental health? 2. What are the positive factors? 3. What are the negative factors? Methodology: This study used mixed methods: a questionnaire and semi-structured interviews. The questionnaire used three pairs of polarised closed-question statements, measured by a Likert Scale, to identify the participant’s attitudes on how COVID-19 had impacted their mental health. It was analysed using the Spearman Rank Correlation Coefficient, to validate whether there was a correlation between their answers to the statement pairs. This was followed by semi-structured interviews, that were conducted with ten participants – selected vii by a random-stratified sample. The interviews measured the participant’s attitudes and opinions further. It was analysed using Interpretivist Phenomenological Analysis (IPA), to identify themes in their answers. The themes were split into positive and negative factors that impact mental health. Results: 103 out of 186 children (55.37%) participated in the questionnaire, whereas105 out of 467 adults (22.48%) participated. The polarised statement pair that asked “COVID-19 has positively/negatively changed the way I cope with stress and anxiety” produced data showing the participants answers were strongly associated with chance. As a result, this meant the results would be difficult for other researchers to replicate. The reason for this was explored in the semi-structured interviews. In them, the most common positive factor cited to have impacted participants mental health was their coping skills. This was also cited as the most common negative factor, as participants explained the pandemic prevented them from seeing their extended families or fulfilling their ‘normal’ daily routines. Conclusions: This study concluded that COVID-19 has had an impact on individual’s mental health both positively and negatively. There were various factors for them that were cited throughout the semi-structured interviews. However, it is unclear how much of an impact it has had on their lives, as the questionnaire shown most of the participants answers were strongly associated with chance. Future work may wish to review this study by conducting a baseline to measure participants perceptions of how COVID-19 has impacted their mental health and then review it several months later to determine how much of an impact the pandemic has had on their lives. Alternatively, some researchers may choose to explore the factors identified in this project and see if they could be applied in other contexts or with a larger population-size. Key Words: COVID-19; Mental health factors; Case study
... Nevertheless, the BPS model continues to have its share of criticism on theoretical and practical grounds alike in the scientific literature. Of all fields of health care, psychiatry and mental health care have not embraced the BPS model or have even argued against it [12,13]. The argumentation is based on the grounds that its boundaries are not sufficiently specific, especially in terms of the psychological approach to be used [14]; that it is not an appropriately developed model at all, and no proper methods are available for investigating its dimensions [15]. ...
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Article
The biopsychosocial model of health in a limited life course perspective was tested among students in higher education using data from a nationwide cross-sectional survey of students on track to become teachers in Hungary. Health determinants were grouped into categories of biological, psychological, and social determinants and arranged in a temporal manner from childhood to the present. The model was tested by canonical correlation analysis followed by multivariate analysis of covariance. One composite outcome of health and six determinant groups were examined out of a total of 24 variables in both genders. Separate sets of health determinants were identified for men and women. The health of men was determined by fewer variables that were more proximal in time, more centred around physical activity, and less influenced by social relations. As opposed to that of men, women’s health was influenced by age; determinants were grouped around the ingestion of various substances and social support. In contrast to men, the health of women seemed to be more obviously multifactorial. The study supports the usefulness of the biopsychosocial model of health in research. The best fit models provided evidence for the importance of gender awareness when designing public health interventions aimed at students.
... Esta perspectiva teórica, aplicada en psiquiatría sostiene que los niveles, biológicos, psicológicos y sociales deben ser siempre tenidos en cuenta, porque todos están involucrados integral e interactivamente en la salud física y la enfermedad 25 . Sin embargo, y a pesar de su aparente atractivo, el modelo no ayuda al clínico a identificar las intervenciones más efectivas, para cada caso en particular, ni el modo en qué éstas deberían ser implementadas 26 . A lo anterior se suma el problema de que este modelo no parece poder contestar la pregunta sobre que es una depresión, ni limitar que es lo biológico, lo psicológico o lo social en cada instancia del fenómeno. ...
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Article
Defining what is meant by “mental illness” has three dimensions: (i) the ontological dimension, which attempts to answer the question of what is a mental illness in itself, (ii) the scientific dimension, which attempts to identify its causes, and (iii) the practical dimension, which will seek a treatment. This article uses depression to examine how various conceptual alternatives in contemporary literature attempted to tackle the problem of what is a mental illness. After evaluating the scope of their proposals in the three dimensions mentioned above, it is concluded that the biomedical model could become a good candidate for developing a useful framework for understanding, having a scientific explanation and treating depression.
... The TTPSS mainly addresses mental health issues of students and the professional competency enhancement of school psychology teachers who are responsible for delivering psychology courses and offering psychological counseling at school. The system is based on the Biopsychosocial Model, which provides the basic paradigm for mental health as it is now broadly accepted that illness and health are the result of the interaction of biological, psychological, and social factors (Engel, 1980;Read et al., 2008;Alvarez et al., 2012), and derives from the Tertiary Disease Prevention Model, which includes three categories of prevention, aiming to prevent disease or injury, reduce the impact of disease or injury, and soften the impact of an ongoing illness or injury respectively (Institute for Work & Health, 2015). ...
... In a BPS-based course, medical students could build up their background knowledge, gain abundant materials from personal or patients' stories, and understand disease from a social and psychological perspective. Through this learning journey, students may be able to analyze meaning and conflicts and critically reflect on the unique wisdom gained from interpreting their own experiences [20][21][22]. ...
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Article
Objective: The biopsychosocial (BPS) model has been proposed to take into account the interaction of psychological and social factors in medical practice. Although some studies have explored its application in medical education, little has been evaluated about students' reflection in such courses. This study introduced a BPS model course and aimed to assess changes in students' reflective capacity resulting from this course. Materials and methods: Eighty-seven written reflections before and after the course were segmented, coded, and rated using the Reflection Evaluation for Learners' Enhanced Competencies Tool rubric, which contains six factors of reflective capacity, namely description of disease experience, presence, attending to emotions, description of conflict or disorienting dilemma, meaning making, and action. Results: After the BPS model course, the overall reflective capacity, as well as the "Presence" and "Meaning making" scores, increased, while scores for "Attending to emotion" decreased significantly. "Description of disease experience," "Description of conflict or disorienting dilemma," and "Action" showed no significant change. Conclusion: Pedagogical suggestions are discussed for a BPS model course with reflective training for young medical students.
... In an African context, the sense of what one is, is defined by refined relationships one has with other selves [157]. A concept of Ubuntu permeates all walks of life [158][159][160][161][162]. It is the gift Africa gives to the world in dealing with drugs. ...
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Article
In dealing with a wave of addiction to whoonga, a heroin variant drug beleaguering mainly Black African youth in South African townships and informal settlements, harm reduction measures take their cue from successes around the world. They call for community-based approaches that include availing opioid substitution therapy, and complementing professional expertise. This non-judgmental approach, compared with the preceding, moral and medical models on drug addiction, is concerned with alleviating negative psychological and social effects associated with addiction to drugs. This paper reviews literature on whoonga addiction in South Africa. The study theorises on the adoption of ecological and recovery approaches to drug addiction as appropriate to a whoonga situation, complementing harm reduction measures at local and community levels of intervention. The study adopted recovery as an organizing concept to give the face, the voice, the vision, choice, and hope that whoonga addiction can be overcome. The dislocation theory is revisited. This theory is consonant with a recovery movement at local level. It advances the idea of eradicating addictions: both interventions involve engaging the community agency.
... As French (2007, p. 31) states, 'impairment is not the causal or determinative factor in bringing the individual into contact with law enforcement and criminal justice agencies, although…it may interact with other "primary" factors to do so' . A psychosocial understanding of overrepresentation draws attention to the interaction between the individual and the multiple systems impacting on a young person's life (Álvarez, Pagani, & Meucci, 2012). While it moves away from linear cause-and-effect explanations and acknowledges complexity, there is a need to incorporate a critical lens to such arguments in order to provide a clear prescription for change (Payne, 2014). ...
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Article
Young people with cognitive disabilities (YPWCD) are overrepresented as offenders in the criminal justice system. However, most existing research on this topic examines overrepresentation in courts and corrections rather than at the police gatekeeping stage of the criminal justice process. Furthermore, while the views of other groups have been documented, the perspectives of service providers – who often bear witness to YPWCD’s interactions with police – have yet to be examined. This research addresses this gap by analysing qualitative interviews with service providers from Queensland, Australia, using the three most common theoretical explanations for the overrepresentation of PWCD (the susceptibility, differential treatment and psychosocial disadvantage theses) as an analytic framework. A number of implications emerged from the study. There is a need to take a critical and intersectional lens to YPWCD’s experiences, as well as to equip police to work with YPWCD to de-escalate interactions with this group.
... Although our study did not articulate the effects that passive coping strategies (such as prolonged patterns of behavioral or social avoidance due to pain) may have played in the outcomes of our patients, it is feasible that a passive approach to pain may have reinforced the high levels of pain-related physical and psychosocial problems noted in our sample. Our results, and those of other researchers, highlight the importance of consideration of the biopsychosocial model [37], not only in understanding the prediction and alleviation of pain but also in physical and mental health outcomes. ...
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Article
Background Evidence suggests social interactions play an important role in pain perception. Purpose The aim of this study was to determine whether social isolation (SI) in people with persistent pain determines pain interference (PI) and physical function over time. Methods Patients seeking care at a tertiary pain management referral center were administered the Patient Reported Outcome Measurement Information System (PROMIS®) SI, PI, physical function, depression, and average pain intensity item banks at their initial consultation and subsequent visits as part of their routine clinical care. We used a post hoc simulation of an experiment using propensity score matching (n = 4,950) and carried out a cross-lagged longitudinal analysis (n = 312) of retrospective observational data. Results Cross-lagged longitudinal analysis showed that SI predicted PI at the next time point, above and beyond the effects of pain intensity and covariates, but not vice versa. Conclusions These data support the importance of SI as a factor in pain-related appraisal and coping and demonstrate that a comprehensive assessment of the individuals’ social context can provide a better understanding of the differential trajectories for a person living with pain. Our study provides evidence that the impact of pain is reduced in individuals who perceive a greater sense of inclusion from and engagement with others. This study enhances the understanding of how social factors affect pain and have implications for how the effectiveness of therapeutic interventions may be improved. Therapeutic interventions aimed at increasing social connection hold merit in reducing the impact of pain on engagement with activities.
... This idea has been endorsed in many academic domains such as health education, health psychology, public health, and preventive medicine as well as in public opinion. [20,21] The BPS approach is today the "conceptual status quo". [22] and underpins the World Health Organization's (WHO) definition of health: "A state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity." ...
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Article
The biopsychosocial (BPS) approach proposed by Engel four decades ago was regarded as one of the most important developments in medicine and psychiatry in the late 20th century. Unlike the biomedical model, the BPS approach posits that biological, psychological, and social factors play a significant role in disease causation and treatment. This approach brought about a new way of conceptualizing mental health difficulties and engendered changes within research, medical teaching and practice. Global mental health (GMH) is a relatively new area of study and practice that seek to bridge inequities and inequality in mental healthcare services provision for people worldwide. The significance of the BPS approach for understanding mental health difficulties is being debated in the context of GMH initiatives. This paper critically evaluates strengths and weaknesses of the BPS approach to mental health difficulties and explores its relevance to GMH initiatives.
... 21 It forms the foundation of two measures of case complexity, the INTERMED 22 and the Oxford Case Complexity Assessment Measure (OCCAM). 23 It is probably the most widely mentioned and used model in research into rehabilitation and disability including chronic pain, psychiatric disorders, 24 and, possibly, functional disorders. ...
Article
The biopsychosocial model outlined in Engel's classic Science paper four decades ago emerged from dissatisfaction with the biomedical model of illness, which remains the dominant healthcare model. Engel's call to arms for a biopsychosocial model has been taken up in several healthcare fields, but it has not been accepted in the more economically dominant and politically powerful acute medical and surgical domains. It is widely used in research into complex healthcare interventions, it is the basis of the World Health Organisation's International Classification of Functioning (WHO ICF), it is used clinically, and it is used to structure clinical guidelines. Critically, it is now generally accepted that illness and health are the result of an interaction between biological, psychological, and social factors. Despite the evidence supporting its validity and utility, the biopsychosocial model has had little influence on the larger scale organization and funding of healthcare provision. With chronic diseases now accounting for most morbidity and many deaths in Western countries, healthcare systems designed around acute biomedical care models are struggling to improve patient-reported outcomes and reduce healthcare costs. Consequently, there is now a greater need to apply the biopsychological model to healthcare management. The increasing proportion of healthcare resource devoted to chronic disorders and the accompanying need to improve patient outcomes requires action; better understanding and employment of the biopsychosocial model by those charged with healthcare funding could help improve healthcare outcome while also controlling costs.
... In line with Ghaemi's critique, one reason for this may be due to the lack of clarity in defining the biopsychosocial model. In a literature review on the application of the biopsychosocial model in the field of mental health, Alvarez, Pagani, and Meucci (2012) reported on 32 full-length articles, written between 1977 and 2010. The authors noted that there was little agreement among terminology, with 18 out of 32 studies using the term biopsychosocial model. ...
... Ce modèle suppose qu'aucune prépondérance a priori ne soit accordée à l'une ou l'autre des trois catégories de déterminants de la santé (biologiques, psychologiques, sociaux), même si l'on conçoit que leur importance relative puisse varier selon le contexte, l'enjeu de santé ou le type de maladie. Le modèle biopsychosocial a été abondamment utilisé dans le champ de la santé mentale et des troubles mentaux afin d'étudier l'influence d'une grande diversité de facteurs [200][201][202][203] 460 participants ont complété un questionnaire en ligne, ce qui correspond à un taux de réponse de 30,1% par rapport à l'échantillon total à T1 (n=1527). ...
... There may be good reasons why psychiatry could profit from the clinical neurosciences, but the common view that neurological diseases are exhaustively understood and treated on the basis of neurophysiological mechanisms seems obsolete. A biopsychosocial framework may be criticized for suffering from eclecticism and for not providing specific treatment options [55,56] , but this does not mean that we cannot decide between the different treatment options in specific cases on empirical grounds. If increasing neuroscientific research can help further elucidating the 'bio' part of mental diseases, potentially leading to new treatment options, this should be highly welcome. ...
Article
Neuroscientific research has substantially increased our knowledge about mental disorders in recent years. Along with these benefits, radical postulates have been articulated according to which understanding and treatment of mental disorders should generally be based on biological terms, such as neurons/brain areas, transmitters, genes etc. Proponents of such a ‘biological psychiatry' claim that mental disorders are analogous to neurological disorders and refer to neurology and neuropsychology to corroborate their claims. The present article argues that, from a clinical-neuropsychological perspective, ‘biological psychiatry' is based on a mechanistic, ‘cerebrocentric' framework of brain (dys-)function which has its roots in experimental neuroscience but runs up against narrow limits in clinical neurology and neuropsychology. In fact, understanding and treating neurological disorders generally demands a systems perspective including brain, organism and environment as intrinsically entangled. In this way, ‘biological' characterizes a ‘holistic', nonreductionist level of explanation, according to which the significance of particular mechanisms can only be estimated in the context of the organism (or person). This is evident in the common observation that local brain damage does not just lead to an isolated loss of function, but to multiple attempts of reorganization and readaptation; it initiates new developments. Furthermore, treating brain disorders necessarily includes aspects of individuality and subjectivity, a conclusion that contradicts the purely ‘objectivist', third-person stance put forward by some proponents of biological psychiatry. In sum, understanding and treating brain damage sequelae in the clinical neurosciences demands a biopsychosocial perspective, for both conceptual and historical reasons. The same may hold for psychiatry when adopting a brain-based view on mental disorders. In such a perspective, biological psychiatry seems an interesting project but falls short of its original claims.
... It is important to view the etiology of mood and anxiety disorders from a biopsychosocial perspective, thus accepting that a variety of factors from an individual's biology, psychology, and environment can contribute to the development of a mood or anxiety disorder (Alvarez, Pagani, & Meucci, 2012). For example, an individual with a family history of depression, bipolar, or anxiety disorder may inherit a predisposition to the disorder, thus increasing their likelihood of eventually developing the disorder. ...
... However, what Cassell seems to lack is a valid causal theory of how the whole person (characterized by the properties often designated as 'mind' or 'psychosocial') can affect the parts like genomes, transcriptomes and proteomes (which in reductionist terms represent 'the body'). This shortcoming also reflects a broader theoretical vacuum in humanistic and biopsychosocial medicine [32,41,60]. ...
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Rationale, aims and objectivesThe practicing doctor, and most obviously the primary care clinician who encounters the full complexity of patients, faces several fundamental but intrinsically related theoretical and practical challenges – strongly actualized by so-called medically unexplained symptoms (MUS) and multi-morbidity. Systems medicine, which is the emerging application of systems biology to medicine and a merger of molecular biomedicine, systems theory and mathematical modelling, has recently been proposed as a primary care-centered strategy for medicine that promises to meet these challenges. Significantly, it has been proposed to do so in a way that at first glance may seem compatible with humanistic medicine. More specifically, it is promoted as an integrative, holistic, personalized and patient-centered approach. In this article, we ask whether and to what extent systems medicine can provide a comprehensive conceptual account of and approach to the patient and the root causes of health problems that can be reconciled with the concept of the patient as a person, which is an essential theoretical element in humanistic medicine.Methods We answer this quetion through a comparative analysis of the theories of primary care doctor Eric Cassell and systems biologist Denis Noble.Results and conclusionsWe argue that, although systems biological concepts, notably Noble's tleory of biological relativity and downward causation, are highly relevant for understanding human beings and health problems, they are nevertheless insufficient in fully bridging the gap to humanistic medicine. Systems biologists are currently unable to conceptualize living wholes, and seem unable to account for meaning, value and symbolic interaction, which are central concepts in humanistic medicine, as constraints on human health. Accordingly, systems medicine as currently envisioned cannot be said to be integrative, holistic, personalized or patient-centered in a humanistic medical sense.
... Based on this model, the conditions which are referred to as unexplained somehow rest on a) biological components such as genes, physiological reactivity, immune responses, b) psychological factors such as coping patterns , personality traits, health-related habits, cognition and c) social factors such as social support from family, social and cultural beliefs. However, advocates of Engel's model, such as Alvarez et al. [39], are sceptical of such an idealised separation of components. They emphasise that the bio-psychosocial model should not at all be interpreted as a theory, a philosophy or a clinical method holding such ideas. ...
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Medically unexplained symptoms (MUS) remain recalcitrant to the medical profession, proving less suitable for homogenic treatment with respect to their aetiology, taxonomy and diagnosis. While the majority of existing medical research methods are designed for large scale population data and sufficiently homogenous groups, MUS are characterised by their heterogenic and complex nature. As a result, MUS seem to resist medical scrutiny in a way that other conditions do not. This paper approaches the problem of MUS from a philosophical point of view. The aim is to first consider the epistemological problem of MUS in a wider ontological and phenomenological context, particularly in relation to causation. Second, the paper links current medical practice to certain ontological assumptions. Finally, the outlines of an alternative ontology of causation are offered which place characteristic features of MUS, such as genuine complexity, context-sensitivity, holism and medical uniqueness at the centre of any causal set-up, and not only for MUS. This alternative ontology provides a framework in which to better understand complex medical conditions in relation to both their nature and their associated research activity.
... Obtaining information about disease entities and their impact on functioning is not entirely new in the field of medicine and health. While the consideration of the disease and its impact on functioning has been in place, or at least acknowledged, for a long time, [6] there remain prevailing issues, such as the lack of wide dissemination and implementation extending beyond simple awareness [7,8]. The operationalization of integrated disease-and-functioning models currently varies, is fragmented across healthcare settings, and is perhaps Maintaining family relationships d760 ...
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To understand the full burden of a health condition, we need the information on the disease and the information on how that disease impacts the functioning of an individual. The ongoing revision of the International Classification of Diseases (ICD) provides an opportunity to integrate functioning information through the International Classification of Functioning, Disability and Health (ICF). Part of the ICD revision process includes adding information from the ICF by way of "functioning properties" to capture the impact of the disease on functioning. The ICD content model was developed to provide the structure of information required for each ICD-11 disease entity and one component of this content model is functioning properties. The activities and participation domains from ICF are to be included as the value set for functioning properties in the ICD revision process. The joint use of ICD and ICF could create an integrated health information system that would benefit the implementation of a standard language-based electronic health record to better capture and understand disease and functioning in healthcare.
Article
Background: The prevalence and comorbidity of anxiety disorders are significantly different between women and men, with research showing a greater impact on women. The aim of this review was to identify the psychosocial and biological factors that have been considered to explain this gender and sex difference in prevalence and determine whether these factors are related to any anxiety comorbidity differences between men and women. Methods: Following the PRISMA guidelines, we carried out a systematic review of studies published between 2008 and 2021 in PsycINFO and PubMed databases. Empirical and review studies evaluating psychosocial and biological factors that could influence the difference in prevalence and comorbidity between men and women were included. A qualitative narrative synthesis was performed to describe the results. Results: From 1012 studies, 44 studies were included. Retrieved articles were categorized depending on their object of study: psychosocial factors (n = 21), biological factors (n = 16), or comorbidity (n = 7). Results showed that differences in anxiety between women and men have been analyzed by psychosocial and biological factors but rarely together. Among the psychosocial factors analyzed, masculinity may be a protective factor for anxiety development, while femininity can be a risk factor. In the studies that took biological factors into account, the potential influence of brain structures, genetic factors, and fluctuations in sexual hormones are pointed out as causes of greater anxiety in women. Concerning comorbidity, the results noted that women tend to develop other internalizing disorders (e.g. depression), while men tend to develop externalizing disorders (e.g. substance abuse). Conclusions: For an accurate understanding of differences between women and men in anxiety, both biological and psychosocial factors should be considered. This review highlights the need to apply the biopsychosocial model of health and the gender perspective to address differences in anxiety between sexes.
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Creating an environment that supports mental health—whether minimizing symptoms of mental health disorders or optimizing subjective well-being—is an ongoing and evolving process for sports organizations. Taking a quality improvement approach to meeting organizational needs related to mental health promotion means being reflexive, intentional, and strategic in planning, implementing, and studying changes, and acting (e.g., course correcting) based on what you find. This process is, in large part, subjective. Organizations should clarify their values, and use these values to guide their quality improvement decision-making. To the extent these values include a commitment to equity, each stage of the quality improvement process should include reflection on whose voices are being heard, whose perspectives and preferences are being centered, and who is deciding what constitutes “success.”KeywordsMental healthOrganizationQuality improvementEquitySport
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Evolutionary psychiatry attempts to explain and examine the development and prevalence of psychiatric disorders through the lens of evolutionary and adaptationist theories. In this edited volume, leading international evolutionary scholars present a variety of Darwinian perspectives that will encourage readers to consider 'why' as well as 'how' mental disorders arise. Using insights from comparative animal evolution, ethology, anthropology, culture, philosophy and other humanities, evolutionary thinking helps us to re-evaluate psychiatric epidemiology, genetics, biochemistry and psychology. It seeks explanations for persistent heritable traits shaped by selection and other evolutionary processes, and reviews traits and disorders using phylogenetic history and insights from the neurosciences as well as the effects of the modern environment. By bridging the gap between social and biological approaches to psychiatry, and encouraging bringing the evolutionary perspective into mainstream psychiatry, this book will help to inspire new avenues of research into the causation and treatment of mental disorders.
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Aim: The paper aims to show how the biopsychosocial (BPS) model can be applied as a clinical method and guide the assessment and treatment of children and adolescents with Somatic Symptom Disorders (SSD). Methods: Based on relevant literature and our clinical work with children and adolescents with SSD we have developed a method to ensure a structured, interdisciplinary examination of biological, psychological and social factors, operationalising the BPS model into a clinical method. Results: The BPS model renders assessment and treatment of complex conditions as a basis for evaluating phenomena not confined by diagnostic tools, but still includes all information from these tools. It requires an interdisciplinary approach, giving individual patient and caregivers a central position. A thorough medical examination is required as a starting point for assessments. Good results rest upon a shared understanding between patient, caregivers and professionals. Conclusions: "Biopsychosocial" is often claimed as a basis for clinical work with complex cases, medical, functional, and psychiatric, but scarcely with a corresponding BPS method or practice. The BPS method should guide further development of holistic, multidisciplinary health care on all levels, in order to assess and help children and adolescents with SSD.
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Sexuality is an important component of human life that can be experienced and expressed in various ways. The interplay of biological, psychological, and social elements has an impact on sexuality. Because sexuality is a multi-causal, multidimensional complex phenomenon, sexual health and dysfunction should be addressed through a multidisciplinary biopsychosocial framework. The biopsychosocial model (BPS) is a paradigm that allows a clinician to explore the cause of a condition or disease based on a combination of biological, psychological, and social factors, and if so, to guide the diagnosis, education, and treatment process using as much evidence-based information as possible. The main principles of the BPS model and the algorithm for the management of sexual dysfunction are discussed in this chapter. When it comes to rare sexual medicine disorders, where evidence and knowledge are scarce, using a BPS approach is a must, as it can lead to a better understanding of the factors at play and, at the very least, allow treatments to be tailored to the patient’s needs.
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Purpose The purpose of this paper is to test a mental wellness intervention, Mood Lifters (ML), that addresses significant barriers to mental health care. ML includes adults over 18 struggling with mental wellness or any life difficulties, except those with active suicidality, mania and psychosis, and addresses barriers to care using peer leaders in a manualized group format with a gamified point system. Design/methodology/approach Participants were recruited using online postings. Those eligible (76% female, 80% white) were randomly assigned to professional-led groups ( N = 30), peer-led groups ( N = 33) or a waitlist ( N = 22; i.e. attended assigned condition if available). Participants completed pre- and postgroup measures (including the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7 and Perceived Stress Scale), attended 15 weekly meetings and tracked “points” or at-home skills practice. Multiple imputation was used to account for attrition. Linear regressions were analyzed to determine the program’s impact on anxiety and depressive symptoms and perceived stress. Further analyses included comparisons between peer- and professional-led groups. Findings Participants in ML experienced significant reductions in anxiety symptoms. Completing more homework across the program led to significant reductions in anxiety and perceived stress. Finally, there were no significant differences in attendance, homework completed or outcomes between peer- and professional-led groups. Practical implications Overall, participation in the ML program led to reduced anxiety symptoms, and for those who completed more homework, reduced perceived stress. More accessible programs can make a significant impact on symptoms and are critical to address the overburdened care system. Additionally, there were no differences between leader types indicating that peers may be an effective way to address accessibility concerns. Originality/value ML is unique for three reasons: it takes a biopsychosocial/Research Domain Criteria approach to mental wellness (i.e. incorporates many areas relevant to mental health, does not focus on a specific diagnosis), overcomes major barriers to mental health care and uses a peer-delivery model. These attributes, taken together with the results of this study, present a care alternative for those with less access.
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Smoking cessation is a major public health goal today as smoking has threatened the safety, health, and lives of millions of people in the global community. Therefore, the purpose of this study is to identify the role of biopsychosocial and spiritual factors towards the readiness to quit smoking and smoking cessation. The results of the study found that smoking behaviour adversely affects not only the biological aspects but also the psychological, social, and spiritual aspects. Apart from that, this study also found that the biological, psychological, social, and spiritual aspects also play an important role in determining the motivation of smokers to quit smoking holistically. Therefore, research and empirical evidence on the biopsychosocial and spiritual aspects are needed to help healthcare teams to identify the barriers and motivating factors to quit smoking.
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This paper explores consumers’ understanding and perception of the etiology of mental illness in community-based residential facilities in Ghana. Qualitative data involving in-depth interviews were used to collect data from 15 consumers of mental health services from two residential facilities. Thematic analysis was used to analyze the data. The study showed that mental illness is generally constructed within the medical and religious-cultural notion. The religious-cultural construction aligned mental illness to Ghanaian belief systems (supernatural forces, spirituality and traditional belief) and cultural practices (social norms and values) whilst the medical construction ascribed the etiology to biological, emotional and substance abuse issues. Although consumers had a positive perception of mental illness, they were doubtful about the presence of illness. The study concludes that the combination of medical, social and religious-cultural constructs and understanding of mental illness should be integrated into advocacy and awareness programmes to better educate consumers and clinicians.
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Introduction Low back pain (LBP) is a global public health problem. It is a highly prevalent and significant source of negative social, psychological, and economic burden. In Ethiopia, LBP ranked in the top ten causes of age standardised disability-adjusted life years (DALYs) in 2015. From 1990 to 2015, while DALYs caused by all other top 30 contributors (such as measles, malaria, and protein energy malnutrition) were shown to decrease, DALYs caused by LBP and sense organ diseases continued to increase (Misganaw et al., 2017b). This shows that combined with neglected tropical diseases, HIV/AIDS, tuberculosis, malaria, and anaemia, which are the common causes of DALYs in sub-Saharan Africa (Vos et al., 2013), LBP may pose a serious burden in Ethiopia. Primary prevention strategies have limited potential while timely and appropriate diagnosis and tailored treatment plans can reduce the burden of pain and improve patient outcomes. A better understanding of the epidemiology of health care utilisation for LBP in resource-limited communities like Ethiopia is therefore significantly important for future health care pathways development (Lentz et al., 2018). Objectives The aims of this study were 1) to develop and validate a measurement instrument used to measure determinants of health care utilisation for LBP, and 2) to investigate the epidemiology of health care utilisation for low back pain in Ethiopia. Methods To develop and validate the measurement instrument, a comprehensive review of the literature was undertaken and the relevant domains of potential determinants of health care utilisation for LBP were identified. Items relating to each domain were then generated, translated, and reviewed by an expert panel for content validity, clarity, and to suggest other items which may have been omitted. Factorial validity and internal consistency reliability were assessed by conducting principal component and parallel analyses, and Cronbach's alpha calculation, respectively, using a data from 1303 completed questions. The intraclass correlation coefficient (ICC) and Cohen Kappa statistic were calculated to evaluate the temporal stability of the instrument. The investigation of health care utilisation and hospital admission for LBP included a total of 1981 people with LBP. The calculation involved a single population proportion formula, with an expected prevalence of health care utilisation for LBP (p = 50%), 95% level of confidence, 4% margin of error, 3 design effect, and a 10% non-response. The study was conducted in June-November 2018 in South-West Shewa zone of Oromia regional state, Ethiopia. The study participants were selected using a multistage sampling technique with a systematic random sampling method. Data were collected using the Oromo language version of the instrument using the interview technique. Data entry was made using Epi-Info version 7.0, where it was exported to SPSS 23.0 and checked for accuracy. Finally, data analyses were carried out using R version 3.5.1. Health care utilisation and hospital admission for LBP were estimated as prevalence rates with 95% confidence intervals (CIs). The log-binomial regression model was fitted to determine prevalence ratios (PR) with 95% CIs in identifying factors associated with health care utilisation and hospital admission for LBP. Estimates of population parameters were also presented with 95% CIs and p-values. For all applications of inferential statistics, a p-value of < 0.05 was taken as the significance level. Results The content validity index of the items forming the newly developed measurement instrument ranged between 0.80 and 1.00 with the modified Kappa coefficient ranged between 0.79 and 1.00. The parallel analysis showed that there were six components with Eigenvalues exceeding the corresponding criterion values for a randomly generated data matrix of the same size. Cronbach's alpha for the internal consistency reliability ranged from 0.65 to 0.82. In assessing temporal stability, ICC ranged from 0.60, 95% CI: 0.23-0.98 to 0.95, 95% CI: 0.81-1.00 while Cohen Kappa ranged from 0.72, 95% CI: 0.49-0.94 to 0.93, 95% CI: 0.85-1.00. The lifetime prevalence of health care utilisation for LBP was 36.1%, 95% CI: 33.9-38.1 and the annual prevalence was 30%, 95% CI: 27.9-32.2. Of the total 543 individuals with a one-year history of presentation to health care facilities for LBP, 78 (14.4%, 95% CI: 11.6-17.3) were hospitalised for the pain, with an average length of stay (LOS) 7.4 days, 95% CI: 6.4-8.8. Several socio-demographic variables, modifiable health behaviours/lifestyle habits, pain interrelated factors, and specific factors, such as beliefs about the pain, depressive symptoms, and sleeping problem/insomnia were independently associated with health care utilisation for LBP. Hospital admission for LBP was also found to be associated with gender, age, living conditions, residential environment, alcohol consumption status, intensity of pain, and presence of additional spinal pain. Conclusions The newly developed measurement instrument has an overall good level of psychometric properties measured as content and factorial validity, internal consistency reliability, and temporal stability. The most decisive factors explaining variations in health care utilisation and hospital admission for LBP were also determined. There were potential inequalities between urban and rural populations in accessing the Ethiopian health care system with relatively better services. This study also highlighted the burden of LBP to individuals and the already overloaded and fragile Ethiopian health care system. It may be prudent that the Ethiopian health care policy makers develop the necessary strategies to meet the health needs of both urban and rural populations with LBP. Further research evidence is also needed on LBP patient referral procedures in the Ethiopian health care system to inform the health policy makers regarding appropriate management strategies capable of dealing with the increasing epidemiology of LBP and associated health needs of people experiencing the pain.
Article
Background: Theories are integral to a research project, providing the logic underlying what, how, and/or why a particular phenomenon happens. Alternatively, models are used to guide a research project by representing theories and visualising the structural framework of causal pathways by showing the different levels of analysis. With the rise in chronic and behaviour-related diseases, health behaviour theories and models have a particular importance in designing appropriate and research led behavioural intervention strategies. However, there is a dearth of papers that explain the role of behavioural theories and models in research projects. Aims: The aim of this paper is to synthesise existing evidence on the relevance of health behaviour theories and models in research projects. Methods: This paper reviews health behaviour theories and models commonly underpinning research projects in public health and clinical practices. The electronic databases, such as MEDLINE, CINAHL, and Scopus, as well as the search engines Google and Google Scholar were searched to identify health behaviour theories and models. Results: Theories and models are essential in a research project. Theories provide the underlying reason for the occurrence of a phenomenon by explaining what the key drivers and outcomes of the target phenomenon are and why, and what underlying processes are responsible for causing that phenomenon. Models on the other hand provide guidance to a research project and assist in visualising the structural framework of causal pathways by showing the different levels of analysis. Health behaviour theories and models in particular offer valuable insights for designing effective and sustainable research projects for improved public health practice. Conclusions: By employing appropriate health behaviour theory and/or model as a research framework, researchers will be able to identify relevant variables and translate these into clinical and public health practices.
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The recent surge in opioid-related deaths has brought poor pain management practices to the forefront of our nation’s collective consciousness. However, improving treatments for chronic pain, substance use disorders (SUD), and comorbid expression of both requires a better understanding of the pathophysiology involved in their development. In this chapter, the authors present the argument that chronic pain and SUD can be conceptualized similarly from a biopsychosocial perspective to inform a better approach to treatment. The authors describe the common neurobehavioral mechanisms of SUD and chronic pain, then discuss the efficacy of several psychotherapeutic methods employed to combat chronic pain, addiction, and related disorders. Such methods may contribute to positive health outcomes in managing chronic pain and curbing drug addiction by reducing the role of opioid analgesics for long-term pain management.
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The biopsychosocial model was initially proposed to overcome the normative assumption that human diseases are exclusively due to disordered biochemical and/or neurophysiological processes. The model attempts to explain how expectations, thoughts and feelings modify the patient’s motivations to deal with illness and recovery. By considering the physical health in this perspective, healthcare professionals may test the importance of socially and culturally shared principles in alleviating illness experience. The entire biopsychosocial hierarchy may thus appear as a complex network of relationships between the strict logic of scientific explanations and the emotional sustainability with which beliefs may either be defended, changed or even refused. In this paper, we aim at reviewing some of the evidence-based biomedical and psychological findings that provide a unified framework for the biopsychosocial model as a multilevel integrative process. To tackle this objective, we propose to approach the model in biosemiotic terms. It is our contention that the entire biopsychosocial hierarchy could be better understood if approached biosemiotically and the multilevel interconnection of this hierarchy re-examined in the light of a collaborative meaning-making process.
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Tarihsel süreç içerisinde sağlık hizmetlerinin odak nesnesi farklı toplum ve zamanlarda değişkenlik göstermiştir. Hastalık merkezli, hasta merkezli, toplum merkezli ve insan merkezli olmak üzere sağlık hizmetinin odağına yerleşen bu kavramlar sağlık hizmeti sisteminin tasarımında belirleyici olmuşlardır. Bunlara çatı oluşturan kavramsal yaklaşımların en önemlileri biyomedikal model ve biyopsikososyal modeldir. Hastalık ve sağlık durumuna ilişkin algılamaları belirleyen bu modeller insana ve insanın sağlık durumuna ilişkin farklı sayıltılara sahiptirler. 1980’li yıllara kadar biyomedikal modelin hâkim olduğu sağlık hizmetleri ve tıbbi pratikler alanı bulunmaktadır. 1948’de Dünya Sağlık Örgütü tarafından sağlık tanımına farklı bir bakış açısı getirilmiş olması biyopsikososyal modelin doğuşunu sağlamıştır. 1980’lerde başlayan sağlık reform dalgası 1990’lara gelindiğinde sağlık sistemlerine insan merkezli sağlık hizmetiyle uyumlu kalite ve akreditasyon çalışmaları entegre edilmiştir. Çalışmada biyopsikososyal modelin sağlık ve hastalık yaklaşımının insan merkezli sağlık uygulamaları ve kalite akreditasyon çalışmalarıyla ilişkisi tartışılmıştır. / ABSTRACT In the historical process, the focus object of health services has changed in different societies and times. These concepts, which are centered on healthcare services such as diseasecentered care, patient-centered care, community-centered care and person-centered care, have been determinative in the design of health care system. The biomedical model and biopsychosocial model are the most important conceptual approaches that provide a framework for these types of care. These models, which determine the perceptions of disease and health status, have different assumptions about human and human health status. Until the 1980s, there was a field of health services and medical practices dominated by the biomedical model. The introduction of a different perspective on the definition of health by WHO in 1948 enabled the development of the biopsychosocial model. The health reform wave that began in the 1980s, and in the 1990s, quality and accreditation activities that are compatible with human- centered health care were integrated into health systems. In this study, the relationship between biopsychosocial model and person-centered health practices and quality accreditation studies is discussed. Keywords: Person-Centered health service, Biomedical model, Biopsychosocial model, Quality in Health Services, Accreditation of Health Services. / Anahtar Kavramlar: İnsan odaklı sağlık hizmeti, Biyomedikal model, Biyopsikososyal model, Kalite, Akreditasyon.
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In this final chapter, Mary Horton-Salway draws together the key points arising from the different perspectives on ADHD, arguing that the meaning of ADHD has been socially constructed through history and there are different ‘translations’, produced by science, in medical practice and in public discourse through accounts of personal experience. The chapter summarises how ‘battles over truth’ have produced ADHD as an epiphenomenal product arising from both scientific and social processes of meaning making. Construction, resistance and contestation are important aspects of how ADHD and other mental health categories are defined and understood across the chapters of this book and these processes are discussed in relation to stigma, the decline of public trust in expert forms of knowledge and in public take up of health knowledge as both consumers and producers. The issue of ‘resistance’ is also discussed in relation to the discourse of neurodiversity and the cultural politics of impairment in categories such as autism or ADHD. The book concludes by considering the relevance of a social constructionist approach to inform educational and clinical practice in mental health care contexts.
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Diagnostic classification systems in psychiatry have continued to rely on clinical phenomenology, despite limitations inherent in that approach. In view of these limitations and recent progress in neuroscience, the National Institute of Mental Health (NIMH) has initiated the Research Domain Criteria (RDoC) project to develop a more neuroscientifically based system of characterizing and classifying psychiatric disorders. The RDoC initiative aims to transform psychiatry into an integrative science of psychopathology in which mental illnesses will be defined as involving putative dysfunctions in neural nodes and networks. However, conceptual, methodological, neuroethical, and social issues inherent in and/or derived from the use of RDoC need to be addressed before any attempt is made to implement their use in clinical psychiatry. This article describes current progress in RDoC; defines key technical, neuroethical, and social issues generated by RDoC adoption and use; and posits key questions that must be addressed and resolved if RDoC are to be employed for psychiatric diagnoses and therapeutics. Specifically, we posit that objectivization of complex mental phenomena may raise ethical questions about autonomy, the value of subjective experience, what constitutes normality, what constitutes a disorder, and what represents a treatment, enablement, and/or enhancement. Ethical issues may also arise from the (mis)use of biomarkers and phenotypes in predicting and treating mental disorders, and what such definitions, predictions, and interventions portend for concepts and views of sickness, criminality, professional competency, and social functioning. Given these issues, we offer that a preparatory neuroethical framework is required to define and guide the ways in which RDoC-oriented research can—and arguably should—be utilized in clinical psychiatry, and perhaps more broadly, in the social sphere.
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This introductory chapter of the Palgrave Handbook of Sociocultural Perspectives on Global Mental Health highlights how understanding about aberrant behaviours has varied across time, geography and culture. Important developments that contributed to the emergence of Global Mental Health are discussed. Rather than a monolithic enterprise, Global Mental Health is presented as a heterogeneous range of practice- and research-based activities concerned with reducing inequities in mental health service provision that has particularly focused on low- and middle-income countries. The chapter summarises debates that have arisen about the relative contribution that particular epistemic frames and research paradigms have made to the development of Global Mental Health. Sociocultural factors are identified as an important, but often neglected, area of Global Mental Health enquiry. The chapter concludes by providing an overview of the three parts of the handbook [1. Mental Health Across The Globe: Conceptual Perspectives From Social Science and the Humanities; 2. Globalising Mental Health: Challenges and Opportunities, 3. Case Studies of Innovative Practice and Policy] and highlights key themes and topics that are covered.
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Thure von Uexküll's reputation as a pioneer in biosemiotics and also in psychosomatic medicine is well documented. It is easy to see these disciplines reflected in his notable publications, both in English and in German. However, if one spares the time to filter through all of his articles, monographs, conference papers and editorials in English and in German, a notable gap arises in his English language publications: that of clinical education. This gap in the English language literature may seem unimportant in and of itself, but it speaks volumes when we consider the total absence of medical semiotics in the curriculum of medical schools in the English speaking world. This runs in stark contrast to the strong traditions of psychosomatic medicine in Germany, which Thure von Uexküll largely helped to instil. Do the works of Thure von Uexküll offer a possible step towards a resurrection of medical semiotics in clinical education? This chapter attempts to explore the lesser known German literature on clinical education that Thure von Uexküll produced, and explore the role semiotics can play in Medical Education in the English speaking world. While also seeking to contrast this literature with other existing approaches in British and American medical schools who have attempted to reintroduce medical humanities and reflexive thinking into clinical education.
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One of the challenges of integrating the biopsychosocial model into medical teaching and practice is the effect of technique on medicine. Relying heavily on the thought of Jacques Ellul, this article defines technique as the systematic application of machine principles to all domains of life, and the evaluation and adjustment of all human activity according to the criterion of efficiency. The article then considers the tension between technique and the biopsychosocial model of medicine, and explores ways to offset the problems technique causes while preserving the good that technique achieves, with particular reference to the teaching of family medicine residents.
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This paper explores the problem of fragmentation in clinical psychology. It is suggested that this is due to the nature of clinical psychology with its multitude of different concerns, ranging from the cultural to the physiological. To help us become more integrative we could more formally adopt the biopsychosocial approach which explicitly asks the clinician and theorist to focus on the interactions between various levels. This paper also argues that the biopsychosocial approach could be informed by evolutionary theory because this theory provides possible explanations of why certain developmental and social contexts can so powerfully impact on physiology. An evolutionary psychology relevant to clinical psychology can focus on the archetypal nature of human experience, be helpful in exploring therapeutic issues, and avoid some of the reductionist aspects of sociobiology.
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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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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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Medical family therapy represents the maturity of the family therapy¿s field emphasizing the collaboration between family therapists and medical providers. This theoretical study describes the evolution of this new discipline from its conception in the biopsychosocial model, to our days, starting with biopsychosocial oriented family theories, family centered medical care and culminating with the creation of medical family therapy. Biopsychosocial oriented family theory emphasized the relationship between health and psychosocial dimensions. Family Oriented Primary Care provided the physician with the counseling skills necessary to address the patient emotional needs regarding medical problems. Finally, Medical Family Therapy applies family therapy techniques in families with specific health problems and its focus is in advocating for patients, family members and health care professionals in integrated health care. Medical family therapy as a new discipline represents the development of family therapy in the practice of biopsychosoical medicine both theoretically and in health care delivery. This paper also addresses political issues that medical family therapy has to face regarding health care in particular the use of the DSM-IV diagnosis.
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Engel's biopsychosocial model, while unifying the sciences relevant to medicine under general systems theory, is of limited utility in organizing bedside clinical problem solving. The authors consider this issue in light of the structure and goals of the clinical encounter. The biopsychosocial model is a model for organizing the sciences relevant to medicine; however, medical/psychiatric practice poses problems both within and outside the scientific realm. Since the biopsychosocial model cannot account for clinical problems to which the methods of science do not apply, the authors seek to facilitate biopsychosocial problem solving by proposing a clinical decision-making model that complements the biopsychosocial model. Their model directs the clinician's attention to three core aspects of the clinical encounter: problems of knowledge, ethics, and pragmatics. The authors reconsider Engel's case of Mr. Glover to demonstrate the anticipatory emphasis of the model. Other clinical examples are used to demonstrate the difficulties arising from mistaking one kind of aspect of medicine for another. When these three aspects of medicine are respected equally, a biopsychosocial practice is unavoidable.
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Orthodoxy traditionally manages to control the potential threat from the unorthodox by a strategy of either marginalisation or incorporation. Having for so long marginalised the social sciences, biomedicine now seeks to incorporate them in a new biopsychosocial alliance. The social sciences should resist such blandishments and, rather than act in complicity with biomedicine, be free to pursue a more critical role in exposing the theoretical and empirical inconsistencies in the biomedical model.
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Twenty years ago, the biopsychosocial model was proposed by George Engel to be the new paradigm for medicine and psychiatry. The model assumed a hierarchical structure of the biological, psychological and social system and simple interactions between the participating systems. This article holds the thesis that the original biopsychosocial model cannot depict psychiatry's reality and problems. The clinical validity of the biopsychosocial model has to be questioned. It is argued that psychiatric interventions can only stimulate but not determine their target systems, because intervention and outcome are only loosely coupled. Thus, psychiatric interventions have in principle limited ranges which differ according to the type of intervention and according to the system to be stimulated. Psychosocial interventions face far more obstacles to be overcome than psychopharmacological therapy.
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The integration of the biopsychosocial model into manual therapy practice is challenging for clinicians, especially for those who have not received formal training in biopsychosocial theory or its application. In this masterclass two contemporary models of health and disability are presented along with a model for organizing clinical knowledge, and a model of reasoning strategies that will assist clinicians in their understanding and application of biopsychosocial theory. All four models emphasise the importance of understanding and managing both the psychosocial and the biomedical aspects of patients' problems. Facilitating change in patients' (and clinicians') perspectives on pain and its biopsychosocial influences requires them to reflect on their underlying assumptions and the basis of those beliefs. Through this reflective process perspectives will be transformed, and for clinicians, in time, different management practices will emerge.
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The object of this study was to assess the change towards a biopsychosocial health concept among medical researchers in the last two decades, after the explicit criticism of the biomedical model in the late 1970s because of its somatic reductionism. The concepts of 'health' or 'healthy status of an individual' as reported as variable in empirical articles published in the journal The Lancet over the years 1978-1982 (period a) and 1996-2000 (period b) were searched by means of Medline and compared for their definition of these variables. None of the 52 examined papers set out a positive and replicable definition of 'health' (seven papers) or 'healthy status' (45). No difference was found between the two periods studied except for the failure of reports to describe 'healthy status' at all (65.5% in a, 19% in b). Most articles do it in an indirect way, namely through exclusion conditions of subjects taking part in treatment or control groups. Only three studies include psychological dimensions in their measures of 'healthy status' (two in a, one in b). Concerning 'health', all seven examined papers include psychological or both psychological and social dimensions. Although a change towards a more holistic concept of health has occurred in academic and institutional contexts over the last few decades, there does not appear to have been a parallel change in the practical domains of medicine. Possible reasons are discussed, specially the difficulty of applying the biopsychosocial model in medical care and the difficulty of competing with the traditional biomedical concept of health, which has proved fruitful and dominant in medicine over the past three centuries.
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The biopsychosocial model is both a philosophy of clinical care and a practical clinical guide. Philosophically, it is a way of understanding how suffering, disease, and illness are affected by multiple levels of organization, from the societal to the molecular. At the practical level, it is a way of understanding the patient's subjective experience as an essential contributor to accurate diagnosis, health outcomes, and humane care. In this article, we defend the biopsychosocial model as a necessary contribution to the scientific clinical method, while suggesting 3 clarifications: (1) the relationship between mental and physical aspects of health is complex--subjective experience depends on but is not reducible to laws of physiology; (2) models of circular causality must be tempered by linear approximations when considering treatment options; and (3) promoting a more participatory clinician-patient relationship is in keeping with current Western cultural tendencies, but may not be universally accepted. We propose a biopsychosocial-oriented clinical practice whose pillars include (1) self-awareness; (2) active cultivation of trust; (3) an emotional style characterized by empathic curiosity; (4) self-calibration as a way to reduce bias; (5) educating the emotions to assist with diagnosis and forming therapeutic relationships; (6) using informed intuition; and (7) communicating clinical evidence to foster dialogue, not just the mechanical application of protocol. In conclusion, the value of the biopsychosocial model has not been in the discovery of new scientific laws, as the term "new paradigm" would suggest, but rather in guiding parsimonious application of medical knowledge to the needs of each patient.
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To examine residents' and medical students' attitudes toward the incorporation of psychosocial factors in diagnosis and treatment and to identify barriers to the integration of evidence-based, mind-body methods. A random sample of third- and fourth-year medical students and residents was drawn from the Masterfiles of the American Medical Association. A total of 661 medical students and 550 residents completed a survey, assessing attitudes toward the role of psychosocial factors and the clinical application of behavioral/mind-body methods. The response rate was 40%. Whereas a majority of students and residents seem to recognize the need to address psychosocial factors, 30%-40% believe that addressing such factors leads to minimal or no improvements in outcomes. The majority of students and residents reports that their training in these areas was ineffective, yet relatively few indicate interest in receiving further training. Females are more likely to believe in the need to address psychosocial factors. Additional factors associated with greater openness to addressing psychosocial factors include (1) the perception that training in these areas was helpful, and (2) personal use of behavioral/mind-body methods to care for one's own health. There is a need for more comprehensive training during medical school and residency regarding both the role of psychosocial factors in health and the application of evidence-based, behavioral/mind-body methods. The current health care structure-particularly insufficient time and inadequate reimbursement for addressing psychosocial factors-may be undermining efforts to improve patient care through inconsistent or nonexistent application of the biopsychosocial model.
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Although advances have been made in specifying connections between biological, psychological, and social processes, the full potential of the biopsychosocial model for health psychology remains untapped. In this article, 4 areas that need to be addressed to ensure the continued evolution of the biopsychosocial model are identified and a series of recommendations concerning initiatives directed at research, training, practice and intervention, and policy are delineated. These recommendations emphasize the need to better understand and utilize linkages among biological, psychological, social, and macrocultural variables. Activities that facilitate the adoption of a multisystem, multilevel, and multivariate orientation among scientists, practitioners, and policymakers will most effectively lead to the kinds of transdisciplinary contributions envisioned by the biopsychosocial perspective.
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In response to G. H. Pollock's (see record 1989-06624-001) discussion of the science–humanism dualism in psychiatry, the present author reviews the work of G. L. Engel (see PA, Vol 59:1423; see also 1988) and M. Reiser (see record 1988-21486-001); discusses the clinical, educational, and research applications of the biopsychosocial hypothesis; and suggests how the biopsychosocial concept will help unify the mental health field. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Objective: To review research evaluations of intensive biopsychosocial training programs for nonpsychiatry residents, and determine whether this research showed sufficient rigor and consistent beneficial impact to allow initial research-based teaching guidelines. Data sources: An English-language literature search used MEDLINE (1966–93), Psychological Abstracts (1967–93), and Educational Resource Information Clearinghouse (1966–93) as well as bibliographic reviews from prominent peer-reviewed articles and consultation with an expert. Study selection: From among several hundred articles about biopsychosocial training, only 12 studies met the selection criteria: at least 100 contact hours of training for nonpsychiatry residents and an evaluation of efficacy. Data extraction: The three authors independently assessed these 12 studies and made a consensus decision based on explicit criteria. Successful and unsuccessful programs were distinguished from among those classified as quasi-experimental or experimental to identify programs of sufficient rigor to meet the study objective; success was defined as learning beyond knowledge and residents’ acceptance of teaching. Data synthesis: Four successful quasi-experimental or experimental programs showed the following uniquely beneficial features: 1) protected time for residents; 2) teaching that was required, structured, multidimensional, and balanced between learner-centered and teacher-centered approaches; 3) teaching methods that used normal as well as psychosocially disturbed patients, nonpsychiatrist teachers, and special teaching techniques; and 4) inclusion in the curriculum of interviewing, interpersonal skills, doctor-patient relationship, and patient education. Two unsuccessful quasi-experimental or experimental programs were unidimensional and unstructured, and used predominant or isolated teacher-centered approaches. Features found in both successful and unsuccessful programs were experiential teaching, psychiatrist and other mental health professional teachers, use of disturbed patients, training to manage patients’ psychosocial problems, teaching directed toward knowledge acquisition, teaching about treatment, and university affiliation. Conclusions: Four rigorously studied, successful programs showed a common pattern of intensive biopsychosocial teaching that produced, in aggregate, improvement in residents’ knowledge, attitudes, skills, and self-awareness. Although there is need for more definitive research, these data are sufficiently compelling and consistent to provide initial, research-based teaching guidelines.
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The biopsychosocial model, the current method in psychiatric assessments, is reviewed and critiqued. The history and original intents leading to the conception of the biopsychosocial model are briefly discussed. Five inherent problems with the use of the biopsychosocial model in psychiatric assessments and training programs are presented. Two alternative approaches are discussed and promoted for clinical, educational, and research practices in medicine.
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The biopsychosocial model is the conceptual status quo of contemporary psychiatry. Although it has played an important role in combatting psychiatric dogmatism, it has devolved into mere eclecticism. Other non-reductionistic approaches to medicine and psychiatry such as William Osler's medical humanism or Karl Jaspers' method-based psychiatry should be reconsidered.
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Educators for the health professions are confronted with choices that could have momentous significance for the future of health care. Educators can continue to try to force medicine into the Procrustean Bed of the biomedical model, with all the divisiveness and fragmentation encouraged by its inherent reductionism and dualism, or they can consider a more comprehensive model that emphasizes psychosocial skills based on a systems approach, with its potential to enhance collaboration, communication and complementarity among the various health professions and enhance the general level of competence of each. That choice and opportunity is especially crucial for those just beginning their education because how the health sciences and health care evolve in the future is to a large degree determined by the approach health profession educators take in training fledgling providers-to-be.
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( This reprinted article originally appeared in Science, 1977, Vol 196[4286], 129–236. The following abstract of the original article appeared in PA, Vol 59:1423. ) Although it seems that acceptance of the medical model by psychiatry would finally end confusion about its goals, methods, and outcomes, the present article argues that current crises in both psychiatry and medicine as a whole stem from their adherence to a model of disease that is no longer adequate for the work and responsibilities of either field. It is noted that psychiatrists have responded to their crisis by endorsing 2 apparently contradictory positions, one that would exclude psychiatry from the field of medicine and one that would strictly adhere to the medical model and limit the work of psychiatry to behavioral disorders of an organic nature. Characteristics of the dominant biomedical model of disease are identified, and historical origins and limitations of this reductionistic view are examined. A biopsychosocial model is proposed that would encompass all factors related to both illness and patienthood. Implications for teaching and health care delivery are considered.
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Two approaches to teaching the biopsychosocial approach were compared. Four outcome measures from 55 patients and 11 resident physicians support a skill-based consultative approach as a more effective teaching method than a traditional didactic method. Implications of this innovative method for the practice of medicine are briefly discussed.
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While remaining influential in education and research in psychiatry and medicine, the biopsychosocial (BPS) model has been criticized for ambiguity in conceptualizing everyday clinical problems. As a multilevel general systems approach, it leaves obscure which system level (cellular, person, family, community, and so on) is most clinically important at any point in time. As a model for psychiatry and medicine, it does not address the practical and moral dimensions of clinical work. This report reviews criticisms and concerns about the BPS model. These criticisms are used to begin a more practicable revision of the model.
Article
A program for teaching a biopsychosocial approach to medical residents was implemented in a medical outpatient clinic. Teaching interventions consisted of a physician-centered focus emphasizing interviewing techniques, a patient-centered focus emphasizing diagnosis and management of psychosocial aspects of the patient's problems, and a physician-patient focus emphasizing the mutually influencing behaviors in the interaction between physician and patient. The effectiveness of the program depended heavily on the active collaboration of the medical attending physicians.
Article
Elsewhere I have discussed the need for medicine to adopt a more inclusive scientific model if physicians in the future are to apply the same scientific rigor to the approach and understanding of patients and their care as they customarily apply to the diagnosis and treatment of disease.1 2 3 In this essay I address the question of who are to be the teachers of such a new scientific model. Because psychiatry has in the past had the main responsibility for education in, broadly speaking, the psychological and social aspects of medicine, it is widely assumed, especially by psychiatrists, that to psychiatry . . .
Article
Proposes that the ultimate challenge facing behavioral medicine is the empirical testing of the biopsychosocial model. Drawing upon S. C. Pepper's (1942) philosophy of science writings, the author illustrates the formistic, mechanistic, contextual, and organistic ways of thinking about health and illness. It is suggested that single-category, single-cause, single-effect models of health and illness are being replaced by multicategory, multicause, multieffect models and that this reflects a major paradigm shift in science in general. Basic aspects of systems theory are applied to the 4 major definitions of behavioral medicine and the 4 major stages of clinical research. The Patient Evaluation Grid is used to highlight how clinical data can be collected biopsychosocially. The emerging roles of psychology as the "middle" discipline and medicine as a biopsychosocial profession are considered in relation to medical education and the practice of behavioral medicine. (31 ref)
Article
How physicians approach patients and the problems they present is much influenced by the conceptual models around which their knowledge is organized. In this paper the implications of the biopsychosocial model for the study and care of a patient with an acute myocardial infarction are presented and contrasted with approaches used by adherents of the more traditional biomedical model. A medical rather than psychiatric patient was selected to emphasize the unity of medicine and to help define the place of psychiatrists in the education of physicians of the future.
Article
Developments in general and living systems theory, in computer science, and in research instrumentation and technology have led to new perspectives on the patient as a person. The biopsychosocial model forces realization that states of health and illness can be understood fully only in terms of their biological, psychological, and social parameters. Research implications of this model, particularly the appreciation it engenders for the brain's role in mediating and regulating transactions along the society-mind-brain-body continuum, are discussed. Objective data generated by skilled clinical psychiatric methods will be needed in addition to data generated in the basic science area for the full range of research challenges in psychiatry to be met.
Article
Throughout the 20th century, a series of rapidly changing emphases have been prominent within psychiatry, each one dominating a period spanning two or more decades. This pattern, along with other historical trends, has contributed to both a diffusion and a confusion about what psychiatry is and what it stands for, affecting the credibility of the profession. As psychiatry approaches the turn of the century, it is critical that psychiatrists and organized psychiatry define and agree upon a coherent vision that will serve as a foundation for a shared understanding with others regarding what the profession represents. Five principal themes are discussed here, emanating from both past and recent history, that can provide this definition to all concerned. The adoption of a biopsychosocial model by all psychiatrists regardless of personal areas of interest or emphasis is the first building block and needs to be coupled with strong support for the continuing evolution of a scientific base and the scientists who are pursuing it. Healthcare reform and the pressures from other nonmedical professions that have reshaped psychiatry's "marketplace" require that a third theme revolve around a reshaping of psychiatry's relationship with the rest of medicine and psychiatrists' interactions with their medical colleagues. Finally, a new set of liaisons with our patients must be built through a redefinition of professional values and an enhanced emphasis on patient rights and responsibilities that will empower our patients to act as our strongest supporters.
Article
To review research evaluations of intensive biopsychosocial training programs for nonpsychiatry residents, and determine whether this research showed sufficient rigor and consistent beneficial impact to allow initial research-based teaching guidelines. An English-language literature search used MEDLINE (1966-93), Psychological Abstracts (1967-93), and Educational Resource Information Clearinghouse (1966-93) as well as bibliographic reviews from prominent peer-reviewed articles and consultation with an expert. From among several hundred articles about biopsychosocial training, only 12 studies met the selection criteria: at least 100 contact hours of training for nonpsychiatry residents and an evaluation of efficacy. The three authors independently assessed these 12 studies and made a consensus decision based on explicit criteria. Successful and unsuccessful programs were distinguished from among those classified as quasi-experimental or experimental to identify programs of sufficient rigor to meet the study objective; success was defined as learning beyond knowledge and residents' acceptance of teaching. Four successful quasi-experimental or experimental programs showed the following uniquely beneficial features: 1) protected time for residents; 2) teaching that was required, structured, multidimensional, and balanced between learner-centered and teacher-centered approaches; 3) teaching methods that used normal as well as psychosocially disturbed patients, nonpsychiatrist teachers, and special teaching techniques; and 4) inclusion in the curriculum of interviewing, interpersonal skills, doctor-patient relationship, and patient education. Two unsuccessful quasi-experimental or experimental programs were unidimensional and unstructured, and used predominant or isolated teacher-centered approaches. Features found in both successful and unsuccessful programs were experiential teaching, psychiatrist and other mental health professional teachers, use of disturbed patients, training to manage patients' psychosocial problems, teaching directed toward knowledge acquisition, teaching about treatment, and university affiliation. Four rigorously studied, successful programs showed a common pattern of intensive biopsychosocial teaching that produced, in aggregate, improvement in residents' knowledge, attitudes, skills, and self-awareness. Although there is need for more definitive research, these data are sufficiently compelling and consistent to provide initial, research-based teaching guidelines.
Article
This paper describes the mental processes by which the psychiatrist organizes and integrates data to produce a case formulation. The biopsychosocial formulation uses three perspectives (biological, psychological and social) to view the data and integrates these viewpoints into one broad, complex and dynamic appreciation of the patient. Guidelines for creating and communicating a case formulation are proposed.
Article
The aim of this review is to provide an analysis of the epistemic status of the biopsychosocial model. A critical comparison of the biopsychosocial model with the general concept of models. In its present form, the biopsychosocial model is so seriously flawed that its continued use in psychiatry is not justified. Further development of theory-based models in psychiatry is urgently needed.
Article
The biopsychosocial model has been a cornerstone for the training of family physicians; however, little is known about the use of this model in community practice. This study, conducted in an urban Native American health center, examined the application of the biopsychosocial model by an experienced family physician (Dr M). Interactions between Dr M and 9 Native Americans with type 2 diabetes were audio-recorded following preliminary interviews. Interpretations of the interactions were elicited from Dr M through interpersonal process recall and interpretive dialogue sessions. The author analyzed this data using techniques from interpretive anthropology and narrative discourse analysis. In a preliminary interview, Dr M described a sophisticated biopsychosocial approach to practice. However, she viewed her actual interactions with these patients as imbued with misunderstanding, mistrust, and disconnection. This occurred in spite of her experience and commitment to providing culturally sensitive primary care. Biopsychosocial models of disease may conflict with patient-centered approaches to communication. To overcome difficulties in her practice environment, Dr M adopted a strategy that combined an instrumental biopsychosocial approach with a utilitarian mode of knowing and interacting with patients. The misunderstandings, mistrust, and constrained interactions point to deeper problems with the way knowledge is formed in clinical practice. We need further understanding of the interrelationships between physicians' clinical environments, knowledge of patients, and theories of disease. These elements are interwoven in the physicians' patient-specific narratives that influence their interactions in primary care settings.
Article
Little is known about how clinicians find common ground in conflicts with their patients or how educators can teach physicians-in-training to do so. The authors set out to create a conceptual model for the process of finding common ground. Students in a third-year family practice clerkship wrote up cases they had encountered in which conflicts arose in the patient-doctor relationship. The authors analyzed these cases, first independently and then collectively. After several iterations, they arrived at a model grounded in the case material. The authors suggest that a modification of the biopsychosocial model first proposed by Engel and later updated by McWhinney is an appropriate and practical schema for classifying sources of conflict. This hierarchical system consists of five levels: (1) individual patient, (2) relationship between patient and physician, (3) patient's family, (4) ethnic belief systems of patient and family, and (5) political economy. This hierarchical, multilevel biopsychosocial approach allows the clinician to identify the level in the system at which a conflict has arisen. This clarifies the strategies for resolution, making it easier for patient and doctor to find common ground. This may also be a useful heuristic model for teaching such skills to physicians-in-training.
Article
A survey of US medical schools regarding the incorporation of psychosomatic (biopsychosocial) medicine topics into medical school curriculum was conducted. The perceived importance and success of this curriculum, barriers to teaching psychosomatic medicine, and curricular needs were also assessed. From August 1997 to August 1999, representatives of US medical schools were contacted to complete a survey instrument either by telephone interview or by written questionnaire. Survey responses were received from 54 of the 118 US medical schools contacted (46%). Responses were obtained from representatives of both public (57%) and private (43%) institutions. Only 20% of respondents indicated that their schools used the term "psychosomatic medicine"; the terms "behavioral medicine" (63%) and "biopsychosocial medicine" (41%) were used more frequently. Coverage of various health habits (eg, substance use and exercise) ranged from 52% to 96%. The conceptualization and/or measurement of psychosocial factors (eg, stress and social support) was taught by 80% to 93% of schools. Teaching about the role of psychosocial factors in specific disease states or syndromes ranged from 33% (renal disease) to 83% (cardiovascular disease). Coverage of treatment-related issues ranged from 44% (relaxation/biofeedback) to 98% (doctor-patient communication). Topics in psychosomatic medicine were estimated to comprise approximately 10% (median response) of the medical school curriculum. On a scale of 1 (lowest) to 10 (highest), ratings of the relative importance of this curriculum averaged 7 (SD = 2.5; range = 2-10). Student response to the curriculum varied from positive to mixed to negative. Perceived barriers to teaching psychosomatic medicine included limited resources (eg, time, money, and faculty), student and faculty resistance, and a lack of continuity among courses. Sixty-three percent of respondents expressed an interest in receiving information about further incorporation of topics in psychosomatic medicine into their school's curriculum. Results of this survey reveal variable coverage of specific psychosomatic medicine topics in the medical school curriculum and differential use of nomenclature to refer to this field. There is a need for further curricular development in psychosomatic medicine in US medical schools.
Article
The authors suggest that pharmacotherapy and psychotherapy, the major treatment modalities in psychiatry, have become fragmented from one another, creating an artificial separation of the psychosocial and biological domains in psychiatry. After a brief discussion of the economic factors influencing this trend, the authors provide a selective overview of recent research. In the absence of systematic empirical data regarding which patients and which conditions might benefit from integrated treatment by one psychiatrist, the authors propose specific clinical situations that call for such integration and also discuss concerns about cost-effectiveness. Recent research suggests that combining psychotherapy and pharmacotherapy may have advantages over either treatment alone in certain clinical situations involving specific disorders. While few of the studies on combined treatment have tested whether a one-person or two-person model of treatment provision is more effective, there are a number of advantages to the one-person treatment model in which a psychiatrist conducts the psychotherapy and prescribes medication for the same patient. The authors suggest that further research is needed to clarify the optimal situations for the one-person model of integrated treatment and also propose systematic teaching of integrated treatment in all residency training programs.
Article
The main objective of the problem-based teaching unit reported in this paper was to introduce psychosocial and psychiatric concepts to first year medical students using an integrated approach. A total of 131 undergraduate students studied a case of delirium. Students were encouraged to understand the problem from a number of perspectives and approaches. In particular, the patient's view was emphasised. This was partially achieved by employing a standardised patient, who answered students' questions about what it was like to be unwell and hospitalised. Both quantitative and qualitative evaluations of the teaching project were conducted. Overall, the teaching project was well received. However, as an introduction to a complex and unfamiliar area, students were concerned that material was difficult to grasp. As a foundation for future teaching in psychiatry, the case and our methods appear appropriate. However, this initial teaching should be reinforced and expanded upon in all years of the medical curriculum.
Article
There is a growing tendency to include in medical curricula teaching programs that promote a biopsychosocial (BPS) approach to patient care. However, we know of no attempts to assess their effect on patterns of care and health care expenditures. To determine whether 1) a teaching intervention aiming to promote a BPS approach to care affects the duration of the doctor-patient encounter, health expenditures, and patient satisfaction with care, and 2) the teaching method employed affects these outcomes. We compared two teaching methods. The first one (didactic) consisted of reading assignments, lectures, and group discussions. The second (interactive) consisted of reading assignments, small group discussions, Balint groups, and role-playing exercises. We videotaped patient encounters 1 month before and 6 months after the teaching interventions, and recorded the duration of the videotaped encounters and whether the doctor had prescribed medications, ordered tests, and referred the patient to consultants. Patient satisfaction was measured by a structured questionnaire. Both teaching interventions were followed by a reduction in medications prescribed and by improved patient satisfaction. Compared to the didactic group, the interactive group prescribed even fewer medications, ordered fewer laboratory examinations, and elicited higher scores of patient satisfaction. The average duration of the encounters after the didactic and interactive teaching interventions was longer than that before by 36 and 42 seconds, respectively. A BPS teaching intervention may reduce health care expenditures and enhance patients' satisfaction, without changing markedly the duration of the encounter. An interactive method of instruction was more effective in achieving these objectives than a didactic one.
Article
Since Engel introduced the biopsychosocial model, it has been extensively examined. The authors expect psychiatrists to formulate cases using the biopsychosocial model. However, resident psychiatrists' ability to generate formulations using this model has received little attention. The authors evaluated resident biopsychosocial formulations using biopsychosocial scores from trained, blinded raters across four institutions. Second, the authors determined if an intervention could improve biopsychosocial formulation. This study included non-experimental and pre-post components using resident portfolio scores to measure biopsychosocial. Residents from four postgraduate years (PGY) in four different programs participated. In one institution, faculty made a concerted effort to improve biopsychosocial formulation. There were 33 entries in 2000-2001 and 46 entries in 2001-2002. Using the combined data from all institutions, no PGY level averaged a rating of 3.0 (competent) in either year. In the institution implementing an intervention, a significant improvement was noted. This pilot study indicates that we can improve resident competency in this area.
Article
With the collapse of the psychoanalytic and the behaviorist models, and the failure of reductive biologism to account for mental life, psychiatry has been searching for a broad, integrative theory on which to base daily practice. The most recent attempt at such a model, Engel's 'biopsychosocial model', has been shown to be devoid of any scientific content, meaning that psychiatry, alone among the medical disciplines, has no recognised scientific basis. It is no coincidence that psychiatry is constantly under attack from all quarters. In order to develop, the discipline requires an integrative and interactive model which can take account of both the mental and the physical dimensions of human life, yet still remain within the materialist scientific ethos. This paper proposes an entirely new model of mind based in Chalmers' 'interactive dualism' which satisfies those needs. It attributes the causation of all behaviour to mental life, but proposes a split in the nature of mentality such that mind becomes a composite function with two, profoundly different aspects. Causation is assigned to a fast, inaccessible cognitive realm operating within the brain machinery while conscious experience is seen as the outcome of a higher order level of brain processing. The particular value of this model is that it immediately offers a practical solution to the mind-brain problem in that, while all information-processing takes place in the mental realm, it is not in the same order of abstraction as perception. This leads to a model of rational interaction which acknowledges both psyche and soma. It can fill the gap left by the demise of Engel's empty 'biopsychosocial model'.
Article
This article presents major concepts and research findings from the field of psychosomatic medicine that the authors believe should be taught to all medical students. The authors asked senior scholars involved in psychosomatic medicine to summarize key findings in their respective fields. The authors provide an overview of the field and summarize core research in basic psychophysiological mechanisms-central nervous system/autonomic nervous system, psychoneuroimmunology, and psychoendocrinology-in three major disease states-cardiovascular, gastrointestinal, and HIV virus infections. Understanding the core scientific concepts and research findings of psychosomatic medicine should provide medical trainees with a scientific foundation for practicing medicine within a biopsychosocial model of care.
The clinical application of the biopsychosocial model.
  • Engel
Engel GL: The clinical application of the biopsychosocial model. Am J Psychiatry 1980;137:535Y44