Biopsychosocial model
Encyclopedia
The biopsychosocial model (abbreviated "BPS") is a general model or approach that posits that biological
, psychological
(which entails thoughts, emotions, and behaviors), and social
factors, all play a significant role in human functioning in the context of disease
or illness. Indeed, health is best understood in terms of a combination of biological, psychological, and social factors rather than purely in biological terms. This is in contrast to the traditional, reductionist
biomedical model
of medicine that suggests every disease process can be explained in terms of an underlying deviation from normal function such as a pathogen
, genetic or developmental abnormality, or injury. The concept is used in fields such as medicine
, nursing
, health psychology
and sociology
, and particularly in more specialist fields such as psychiatry
, health psychology
, family therapy
, chiropractic
, clinical social work, and clinical psychology
. The biopsychosocial paradigm is also a technical term for the popular concept of the "mind–body connection", which addresses more philosophical arguments between the biopsychosocial and biomedical models, rather than their empirical exploration and clinical application.
The model was theorized by psychiatrist
George L. Engel at the University of Rochester
, and putatively discussed in a 1977 article in Science
, where he posited "the need for a new medical model"; however no single definitive, irreducible model has been published. However, the general BPS model has guided formulation and testing of models within each professional field. Interestingly, evidence for the application of the biopsychosocial model was found in ancient Asian (2600 B.C.) (cf Chinese medicine) and Greek (500 B.C.) civilizations prior to Engel's introduction of the theory in 1977. The novelty, acceptance, and prevalence of the biopsychosocial model varies across cultures.
The biopsychosocial model of health is based in part on social cognitive theory
. The biopsychosocial model implies that treatment of disease processes, for example type two diabetes and cancer
, requires that the health care team address biological
, psychological
and social
influences upon a patient's functioning. In a philosophical sense, the biopsychosocial model states that the workings of the body can affect the mind, and the workings of the mind can affect the body. This means both a direct interaction between mind and body as well as indirect effects through intermediate factors.
The biopsychosocial model presumes that it is important to handle the three together as a growing body of empirical literature suggests that patient perceptions of health and threat of disease, as well as barriers in a patient's social or cultural environment, appear to influence the likelihood that a patient will engage in health-promoting or treatment behaviors, such as medication taking, proper diet or nutrition
, and engaging in physical activity.
While operating from a BPS framework requires that more information be gathered during a consultation, a growing trend in US healthcare (and already well-established in Europe such as in the U.K. & Germany) includes the integration of professional services through integrated disciplinary teams, to provide better care and address the patient's needs at all three levels. As seen, for example in integrated primary care clinics, such as used in the U.K., Germany, U.S. Veteran's Administration, U.S. military, Kaiser Permanente, integrated teams may comprise physicians, nurses, health psychologists, social workers, and other specialties to address all three aspects of the BPS framework, allowing the physician to focus on predominantly biological mechanisms of the patient's complaints See also
Psychosocial factors can cause a biological effect by predisposing the patient to risk factors. An example is that depression
by itself may not cause liver
problems, but a depressed person may be more likely to have alcohol
problems, and therefore liver damage. Perhaps it is this increased risk-taking that leads to an increased likelihood of disease. Most diseases in BPS discussion are such behaviourally-moderated illnesses, with known high risk factors, or so-called "biopsychosocial illnesses/disorders". An example of this is type 2 diabetes, which with the growing prevalence of obesity and physical inactivity, is on course to become a worldwide pandemic. For example, approximately 20 million Americans are estimated to have diabetes, with 90% to 95% considered type 2.
It is important to note that the biopsychosocial model does not provide a straightforward, testable model to explain the interactions or causal influences (that is, amount of variance accounted for) by each of the components (biological, psychological, or social). Rather, the model has been a general framework to guide theoretical and empirical exploration, which has amassed a great deal of research since Engel's 1977 article. One of the areas that has been greatly influenced is the formulation and testing of social-cognitive models of health behavior over the past 30 years. While no single model has taken precedence, a large body of empirical literature has identified social-cognitive (the psyho-social aspect of Engel's model) variables that appear to influence engagement in healthy behaviors and adhere to prescribed medical regimens, such as self-efficacy, in chronic diseases such as type 2 diabetes, cardiovascular disease, etc. These models include the Health Belief Model
, Theory of Reasoned Action
and Theory of Planned Behavior
, Transtheoretical Model
, the Relapse Prevention Model, Gollwitzer's implementation-intentions
, the Precaution–Adoption Model, the Health Action Process Approach
, etc.
, as "biopsychosocial" becomes one more disingenuous euphemism
for psychosomatic illness. This may be exploited by medical insurance companies or government welfare departments eager to limit or deny access to medical and social care.
Some psychiatrists see the BPS model as flawed, in either formulation or application. Epstein and colleagues describe six conflicting interpretations of what the model might be, and proposes that "...habits of mind may be the missing link between a biopsychosocial intent and clinical reality." Psychiatrist Hamid Tavakoli argues that the BPS model should be avoided because it unintentionally promotes an artificial distinction between biology and psychology, and merely causes confusion in psychiatric assessments and training programs, and that ultimately it has not helped the cause of trying to destigmatize mental health.
Sociologist David Pilgrim suggests that a necessary pragmatism and a form of "mutual tolerance" (Goldie, 1977) has forced a co-existence of perspectives, rather than a genuine "theoretical integration as a shared BPS orthodoxy." Pilgrim goes on to state that despite "scientific and ethical virtues," the BPS model "...has not been properly realised. It seems to have been pushed into the shadows by a return to medicine and the re-ascendancy of a biomedical model."
However, a vocal philosophical critic of the BPS model, psychiatrist Niall McLaren, writes:
The rationale for this theoretical vacuum is outlined in his 1998 paper and more recently in his books, most notably Humanizing Psychiatrists. Simply put, the purpose of a scientific model is to see if a scientific theory
works and to actualize its logical consequences. In this sense, models are real and their material consequences can be measured, whereas theories are ideas and can no more be measured than daydreams. Model-building separates theories with a future from those that always remain dreams. An example of a true scientific model is longer necked giraffes reach more food, survive at higher rates, and pass on this longer neck trait to their progeny. This is a model (natural selection) of the theory of evolution. Therefore, from an epistemological stance there can be no model of mental disorder without first establishing a theory of the mind
. Dr. McLaren does not say that the biopsychosocial model is devoid of merit, just that it does not fit the definition of a scientific model (or theory) and does not "reveal anything that would not be known (implicitly, if not explicitly) to any practitioner of reasonable sensitivity." He states that the biopsychosocial model should be seen in a historical context as bucking against the trend of biological reductionism, which was (and still is) overtaking psychiatry. Engel "has done a very great service to orthodox psychiatry in that he legitimised the concept of talking to people as people." In short, even though it is correct to say that sociology, psychology, and biology are factors in mental illness, simply stating this obvious fact does not make it a model in the scientific sense of the word.
Biology
Biology is a natural science concerned with the study of life and living organisms, including their structure, function, growth, origin, evolution, distribution, and taxonomy. Biology is a vast subject containing many subdivisions, topics, and disciplines...
, psychological
Psychology
Psychology is the study of the mind and behavior. Its immediate goal is to understand individuals and groups by both establishing general principles and researching specific cases. For many, the ultimate goal of psychology is to benefit society...
(which entails thoughts, emotions, and behaviors), and social
Social
The term social refers to a characteristic of living organisms...
factors, all play a significant role in human functioning in the context of disease
Disease
A disease is an abnormal condition affecting the body of an organism. It is often construed to be a medical condition associated with specific symptoms and signs. It may be caused by external factors, such as infectious disease, or it may be caused by internal dysfunctions, such as autoimmune...
or illness. Indeed, health is best understood in terms of a combination of biological, psychological, and social factors rather than purely in biological terms. This is in contrast to the traditional, reductionist
Reductionism
Reductionism can mean either an approach to understanding the nature of complex things by reducing them to the interactions of their parts, or to simpler or more fundamental things or a philosophical position that a complex system is nothing but the sum of its parts, and that an account of it can...
biomedical model
Biomedical model
The biomedical model of medicine has been around since the mid-nineteenth century as the predominant model used by physicians in diagnosing diseases.It has four core elements....
of medicine that suggests every disease process can be explained in terms of an underlying deviation from normal function such as a pathogen
Pathogen
A pathogen gignomai "I give birth to") or infectious agent — colloquially, a germ — is a microbe or microorganism such as a virus, bacterium, prion, or fungus that causes disease in its animal or plant host...
, genetic or developmental abnormality, or injury. The concept is used in fields such as medicine
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
, nursing
Nursing
Nursing is a healthcare profession focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life from conception to death....
, health psychology
Health psychology
Health psychology is concerned with understanding how biological, psychological, environmental, and cultural factors are involved in physical health and illness. Health psychologists work alongside other medical professionals in clinical settings, work on behavior change in public health promotion,...
and sociology
Sociology
Sociology is the study of society. It is a social science—a term with which it is sometimes synonymous—which uses various methods of empirical investigation and critical analysis to develop a body of knowledge about human social activity...
, and particularly in more specialist fields such as psychiatry
Psychiatry
Psychiatry is the medical specialty devoted to the study and treatment of mental disorders. These mental disorders include various affective, behavioural, cognitive and perceptual abnormalities...
, health psychology
Health psychology
Health psychology is concerned with understanding how biological, psychological, environmental, and cultural factors are involved in physical health and illness. Health psychologists work alongside other medical professionals in clinical settings, work on behavior change in public health promotion,...
, family therapy
Family therapy
Family therapy, also referred to as couple and family therapy, family systems therapy, and family counseling, is a branch of psychotherapy that works with families and couples in intimate relationships to nurture change and development. It tends to view change in terms of the systems of...
, chiropractic
Chiropractic
Chiropractic is a health care profession concerned with the diagnosis, treatment and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health. It is generally categorized as complementary and alternative medicine...
, clinical social work, and clinical psychology
Clinical psychology
Clinical psychology is an integration of science, theory and clinical knowledge for the purpose of understanding, preventing, and relieving psychologically-based distress or dysfunction and to promote subjective well-being and personal development...
. The biopsychosocial paradigm is also a technical term for the popular concept of the "mind–body connection", which addresses more philosophical arguments between the biopsychosocial and biomedical models, rather than their empirical exploration and clinical application.
The model was theorized by psychiatrist
Psychiatrist
A psychiatrist is a physician who specializes in the diagnosis and treatment of mental disorders. All psychiatrists are trained in diagnostic evaluation and in psychotherapy...
George L. Engel at the University of Rochester
University of Rochester
The University of Rochester is a private, nonsectarian, research university in Rochester, New York, United States. The university grants undergraduate and graduate degrees, including doctoral and professional degrees. The university has six schools and various interdisciplinary programs.The...
, and putatively discussed in a 1977 article in Science
Science (journal)
Science is the academic journal of the American Association for the Advancement of Science and is one of the world's top scientific journals....
, where he posited "the need for a new medical model"; however no single definitive, irreducible model has been published. However, the general BPS model has guided formulation and testing of models within each professional field. Interestingly, evidence for the application of the biopsychosocial model was found in ancient Asian (2600 B.C.) (cf Chinese medicine) and Greek (500 B.C.) civilizations prior to Engel's introduction of the theory in 1977. The novelty, acceptance, and prevalence of the biopsychosocial model varies across cultures.
Model description and application in medicine
The biological component of the biopsychosocial model seeks to understand how the cause of the illness stems from the functioning of the individual's body. The psychological component of the biopsychosocial model looks for potential psychological causes for a health problem such lack of self-control, emotional turmoil, and negative thinking. The social part of the biopsychosocial model investigates how different social factors such as socioeconomic status, culture, poverty, technology, and religion can influence health.The biopsychosocial model of health is based in part on social cognitive theory
Social cognitive theory
Social cognitive theory, used in psychology, education, and communication, posits that portions of an individual's knowledge acquisition can be directly related to observing others within the context of social interactions, experiences, and outside media influences.-History:Social cognitive theory...
. The biopsychosocial model implies that treatment of disease processes, for example type two diabetes and cancer
Cancer
Cancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
, requires that the health care team address biological
Biology
Biology is a natural science concerned with the study of life and living organisms, including their structure, function, growth, origin, evolution, distribution, and taxonomy. Biology is a vast subject containing many subdivisions, topics, and disciplines...
, psychological
Psychology
Psychology is the study of the mind and behavior. Its immediate goal is to understand individuals and groups by both establishing general principles and researching specific cases. For many, the ultimate goal of psychology is to benefit society...
and social
Society
A society, or a human society, is a group of people related to each other through persistent relations, or a large social grouping sharing the same geographical or virtual territory, subject to the same political authority and dominant cultural expectations...
influences upon a patient's functioning. In a philosophical sense, the biopsychosocial model states that the workings of the body can affect the mind, and the workings of the mind can affect the body. This means both a direct interaction between mind and body as well as indirect effects through intermediate factors.
The biopsychosocial model presumes that it is important to handle the three together as a growing body of empirical literature suggests that patient perceptions of health and threat of disease, as well as barriers in a patient's social or cultural environment, appear to influence the likelihood that a patient will engage in health-promoting or treatment behaviors, such as medication taking, proper diet or nutrition
Nutrition
Nutrition is the provision, to cells and organisms, of the materials necessary to support life. Many common health problems can be prevented or alleviated with a healthy diet....
, and engaging in physical activity.
While operating from a BPS framework requires that more information be gathered during a consultation, a growing trend in US healthcare (and already well-established in Europe such as in the U.K. & Germany) includes the integration of professional services through integrated disciplinary teams, to provide better care and address the patient's needs at all three levels. As seen, for example in integrated primary care clinics, such as used in the U.K., Germany, U.S. Veteran's Administration, U.S. military, Kaiser Permanente, integrated teams may comprise physicians, nurses, health psychologists, social workers, and other specialties to address all three aspects of the BPS framework, allowing the physician to focus on predominantly biological mechanisms of the patient's complaints See also
Psychosocial factors can cause a biological effect by predisposing the patient to risk factors. An example is that depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
by itself may not cause liver
Liver
The liver is a vital organ present in vertebrates and some other animals. It has a wide range of functions, including detoxification, protein synthesis, and production of biochemicals necessary for digestion...
problems, but a depressed person may be more likely to have alcohol
Ethanol
Ethanol, also called ethyl alcohol, pure alcohol, grain alcohol, or drinking alcohol, is a volatile, flammable, colorless liquid. It is a psychoactive drug and one of the oldest recreational drugs. Best known as the type of alcohol found in alcoholic beverages, it is also used in thermometers, as a...
problems, and therefore liver damage. Perhaps it is this increased risk-taking that leads to an increased likelihood of disease. Most diseases in BPS discussion are such behaviourally-moderated illnesses, with known high risk factors, or so-called "biopsychosocial illnesses/disorders". An example of this is type 2 diabetes, which with the growing prevalence of obesity and physical inactivity, is on course to become a worldwide pandemic. For example, approximately 20 million Americans are estimated to have diabetes, with 90% to 95% considered type 2.
It is important to note that the biopsychosocial model does not provide a straightforward, testable model to explain the interactions or causal influences (that is, amount of variance accounted for) by each of the components (biological, psychological, or social). Rather, the model has been a general framework to guide theoretical and empirical exploration, which has amassed a great deal of research since Engel's 1977 article. One of the areas that has been greatly influenced is the formulation and testing of social-cognitive models of health behavior over the past 30 years. While no single model has taken precedence, a large body of empirical literature has identified social-cognitive (the psyho-social aspect of Engel's model) variables that appear to influence engagement in healthy behaviors and adhere to prescribed medical regimens, such as self-efficacy, in chronic diseases such as type 2 diabetes, cardiovascular disease, etc. These models include the Health Belief Model
Health Belief Model
The health belief model is a health behavior change and psychological model developed by Irwin M. Rosenstock in 1966 for studying and promoting the uptake of health services. The model was furthered by Becker and colleagues in the 1970s and 1980s...
, Theory of Reasoned Action
Theory of reasoned action
The theory of reasoned action , developed by Martin Fishbein and , derived from previous research that started out as the theory of attitude, which led to the study of attitude and behavior...
and Theory of Planned Behavior
Theory of planned behavior
In psychology, the theory of planned behavior is a theory about the link between attitudes and behavior. It was proposed by Icek Ajzen as an extension of the theory of reasoned action. It is one of the most predictive persuasion theories...
, Transtheoretical Model
Transtheoretical Model
The Transtheoretical Model of Behavior Change assesses an individual's readiness to act on a new healthier behavior, and provides strategies, or processes of change to guide the individual through the stages of change to action and maintenance....
, the Relapse Prevention Model, Gollwitzer's implementation-intentions
Implementation intention
An implementation intention is a self-regulatory strategy in the form of an if-then-plan that can lead to better goal attainment. It is subordinate to goal intentions as it specifies the when, where and how of a goal-directed behavior...
, the Precaution–Adoption Model, the Health Action Process Approach
Health Action Process Approach
Health behavior change refers to a replacement of health-compromising behaviors by health-enhancing behaviors . To describe, predict, and explain such processes, theories or models are being developed...
, etc.
Criticism
Some critics point out this question of distinction and of determination of the roles of illness and disease runs against the growing concept of the patient–doctor partnership or patient empowermentPatient empowerment
The patient empowerment concept, a recent outgrowth of the natural health movement, asserts that to be truly healthy, people must bring about changes in their social situations and in the environment that influences their lives, not only in their personal behavior.According to advocates of the...
, as "biopsychosocial" becomes one more disingenuous euphemism
Euphemism
A euphemism is the substitution of a mild, inoffensive, relatively uncontroversial phrase for another more frank expression that might offend or otherwise suggest something unpleasant to the audience...
for psychosomatic illness. This may be exploited by medical insurance companies or government welfare departments eager to limit or deny access to medical and social care.
Some psychiatrists see the BPS model as flawed, in either formulation or application. Epstein and colleagues describe six conflicting interpretations of what the model might be, and proposes that "...habits of mind may be the missing link between a biopsychosocial intent and clinical reality." Psychiatrist Hamid Tavakoli argues that the BPS model should be avoided because it unintentionally promotes an artificial distinction between biology and psychology, and merely causes confusion in psychiatric assessments and training programs, and that ultimately it has not helped the cause of trying to destigmatize mental health.
Sociologist David Pilgrim suggests that a necessary pragmatism and a form of "mutual tolerance" (Goldie, 1977) has forced a co-existence of perspectives, rather than a genuine "theoretical integration as a shared BPS orthodoxy." Pilgrim goes on to state that despite "scientific and ethical virtues," the BPS model "...has not been properly realised. It seems to have been pushed into the shadows by a return to medicine and the re-ascendancy of a biomedical model."
However, a vocal philosophical critic of the BPS model, psychiatrist Niall McLaren, writes:
"Since the collapse of the 19th century models (psychoanalysis, biologism and behaviourism), psychiatrists have been in search of a model that integrates the psyche and the soma. So keen has been their search that they embraced the so-called 'biopsychosocial model' without ever bothering to check its details. If, at any time over the last three decades, they had done so, they would have found it had none. This would have forced them into the embarrassing position of having to acknowledge that modern psychiatry is operating in a theoretical vacuum."
The rationale for this theoretical vacuum is outlined in his 1998 paper and more recently in his books, most notably Humanizing Psychiatrists. Simply put, the purpose of a scientific model is to see if a scientific theory
Scientific theory
A scientific theory comprises a collection of concepts, including abstractions of observable phenomena expressed as quantifiable properties, together with rules that express relationships between observations of such concepts...
works and to actualize its logical consequences. In this sense, models are real and their material consequences can be measured, whereas theories are ideas and can no more be measured than daydreams. Model-building separates theories with a future from those that always remain dreams. An example of a true scientific model is longer necked giraffes reach more food, survive at higher rates, and pass on this longer neck trait to their progeny. This is a model (natural selection) of the theory of evolution. Therefore, from an epistemological stance there can be no model of mental disorder without first establishing a theory of the mind
Theory of mind
Theory of mind is the ability to attribute mental states—beliefs, intents, desires, pretending, knowledge, etc.—to oneself and others and to understand that others have beliefs, desires and intentions that are different from one's own...
. Dr. McLaren does not say that the biopsychosocial model is devoid of merit, just that it does not fit the definition of a scientific model (or theory) and does not "reveal anything that would not be known (implicitly, if not explicitly) to any practitioner of reasonable sensitivity." He states that the biopsychosocial model should be seen in a historical context as bucking against the trend of biological reductionism, which was (and still is) overtaking psychiatry. Engel "has done a very great service to orthodox psychiatry in that he legitimised the concept of talking to people as people." In short, even though it is correct to say that sociology, psychology, and biology are factors in mental illness, simply stating this obvious fact does not make it a model in the scientific sense of the word.
See also
- Activities of daily livingActivities of daily livingActivities of Daily Living is a term used in healthcare to refer to daily self-care activities within an individual's place of residence, in outdoor environments, or both...
- Bodymind
- Brain BloggerBrain BloggerBrain Blogger is an award winning Scientific American partner biomedical blog sponsored by the Global Neuroscience Initiative Foundation and edited by Dr. Shaheen Lakhan...
- Diathesis–stress model
- Health psychologyHealth psychologyHealth psychology is concerned with understanding how biological, psychological, environmental, and cultural factors are involved in physical health and illness. Health psychologists work alongside other medical professionals in clinical settings, work on behavior change in public health promotion,...
- PsychoneuroimmunologyPsychoneuroimmunologyPsychoneuroimmunology is the study of the interaction between psychological processes and the nervous and immune systems of the human body...
- Psychosomatic medicine
External links
- Bracken, Patrick, Thomas, Philip, "Time to move beyond the mind-body split", editorial, British Medical JournalBritish Medical JournalBMJ is a partially open-access peer-reviewed medical journal. Originally called the British Medical Journal, the title was officially shortened to BMJ in 1988. The journal is published by the BMJ Group, a wholly owned subsidiary of the British Medical Association...
2002;325:1433-1434 (21 December) - "Society of Behavioral Medicine"
- "American Diabetes Association"