Biopsychosocial model

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Biopsychosocial models are a class of trans-disciplinary models which look at the interconnection between biology, psychology, and socio-environmental factors. These models specifically examine how these aspects play a role in a range of topics but mainly psychiatry, health and human development.  

The term is generally used to describe a model advocated by George L. Engel in 1977. The model builds upon the idea that "illness and health are the result of an interaction between biological, psychological, and social factors."^[1] which according to Derick T. Wade and Peter W. Halligan, as of 2017, is generally accepted.  The idea behind the model was to express mental distress as a triggered response of a disease that a person is genetically vulnerable when stressful life events occur. In that sense, it is also known as vulnerability-stress model.^[2] It is now referred to as a generalized model that interprets similar aspects,^[3] and has become an alternative to the biomedical and/or psychological dominance of many health care systems. The biopsychosocial model has been growing in interest for researchers in healthcare and active medical professionals in the past decade.^[4]

George L. Engel and Jon Romano of the University of Rochester in 1977, are widely credited with being the first to propose a biopsychosocial model.^[5] However, it had been proposed 100 years earlier and by others.^[6] Engel struggled with the then-prevailing biomedical approach to medicine as he strove for a more holistic approach by recognizing that each patient has their own thoughts, feelings, and history.^[7][6] In developing his model, Engel framed it for both illnesses and psychological problems.

The biopsychosocial model is not just one of many competing possibilities - another intelligently constructed explanation of health. Its emergence is best understood within a historical context. The biopsychosocial model's emergence in psychiatry was influenced by the credibility problem in psychiatry as a medical specialism that arose during wartime conditions.  

By the 20th century, psychiatry was still a relatively new field. In the Victorian era, psychiatry was faced with two key challenges: firstly, taking control of the asylum system from lay administrators and secondly, constructing a credible knowledge base for medical authority over mental illness. At the time, the solution to this was developing a rhetoric of justification for psychiatry which was that the brain is the root of insanity, and physicians are the guardians of mental health. This position both reflected and contributed to the rise of eugenics thought in western intellectual culture. However, this was challenged by the shellshock problem after World War I – there was a fundamental incompatibility between a eugenic view of lunacy and the sad reality of respectable men breaking down with predictable regularity in the war trenches. This led to the recognition of neurosis and acceptance of psychoanalysis in psychiatric discourse. A year after the end of the war, the British Psychoanalytical Society and the Medical Section of the British Psychological Society were both established, marking the start of a nuanced interplay between biological psychiatry and medical psychotherapy. The Tavistock Clinic played a significant role in bridging the gap between these approaches and favoured a unified psychosomatic approach. Under these conditions, the biopsychosocial model was set up to revolutionise our understanding of psychiatry and health.^[8]

There are a number of key theorists that predate the biopsychosocial model. For example, Engel broadened medical thinking by re-proposing a separation of body and mind. The idea of mind–body dualism goes back at least to René Descartes, but was forgotten during the biomedical approach. Engel emphasized that the biomedical approach is flawed because the body alone does not contribute to illness.^[9] Instead, the individual mind (psychological and social factors) play a significant role in how an illness is caused and how it is treated. Engel proposed a dialogue between the patient and the doctor in order to find the most effective treatment solution.^[10]

The idea that there are several factors that may contribute to one's mental suffering is nothing new.^[11] Past psychologists such as Urie Bronfenbrenner, popularized the belief that social factors play a role in developing illnesses and behaviors. Simply, Engel used Bronfenbrenner's research as a column of his biopsychosocial model and framed this model to display health at the center of social, psychological, and biological aspects.

Adolf Meyer's psychobiology model is considered the forerunner to the biopsychosocial model by many. Meyer emphasised understanding mental illness in the context of a patient's personal history over diagnostic categories.^[12] Meyer laid down the groundwork for understanding the interplay of psychology and biology but tended to view these as separate entities that interacted. Engel's model represents a broader and more integrated approach that considers biological, psychological, and social factors as interconnected elements.^[8]

However, Roy Grinker actually coined the term 'biopsychosocial' long before Engel (1954 vs 1977).^[13] The difference between the two researchers is that Grinker sought to highlight biological aspects of mental health. Engel instead emphasised psychosocial aspects of general health.

After publication, the biopsychosocial model was adopted by the World Health Organization (WHO) in 2002 as a basis for the International Classification of Function (ICF).^[14] However, The WHO definition of health adopted in 1948 clearly implied a broad socio-medical perspective.^[15]

The patients that fall under the biopsychosocial model may not fall under the biomedical model, as the biopsychosocial model considers factors that may not physiologically manifest in a person.^[16] By broadening the scope of patients that are encompassed in healthcare, the biopsychosocial model incorporates the idea of non-biological factors such as socioeconomic status, race, and sex to be important components to one's health along with the common biological indicators. Until recent years, the conventional method for handling health and illness centered around the medical or biological model, concentrating solely on medical interventions to address an individual's health issues.^[17] While this approach was once deemed sufficient, contemporary research within psychology and the social sciences has cast doubt on its effectiveness. Scholars are now working on developing a broader health model, incorporating insights from psychology and social sciences, with the intention of improving its practical application in clinical settings.^[17]

Patient populations that the biopsychosocial model accounts for that may not be considered under the biomedical model include those affected by health inequities and those at risk of infirmity.  

Health inequities, often rooted in social determinants of health, highlight the disparities in health outcomes experienced by different populations.^[18] The biopsychosocial model, which considers biological, psychological, and social factors in understanding health, provides a framework for comprehending how these disparities arise and persist, which makes it a model of interest in targeting health inequities.^[19] A holistic biopsychosocial model approach considers additional elements influencing the perceived necessity for healthcare and the focus on health-related matters: Information, Beliefs, and Conduct. Based on the model's dependence on perception, it has been considered imperative to actively engage the individuals or communities whose requirements are being addressed,^[20] regardless of whether the focus is on their health, education, employment, housing, or any other needs. A key term in the biopsychosocial model is "syndemic" which refers to a set of health problem factors that interact synergistically with each other ranging from socioeconomic status to genetics.^[20]

Preventative medicine is a large component of biopsychosocial model which considers preventative measures to stop patients from obtaining infirmity in the first place.^[21] By combatting preventable chronic diseases which make up a majority of deaths in patients of the US, the BPS model has been considered a potential tool to improve patient outcomes.^[22]  

The biomedical and biopsychosocial models offer distinct perspectives on understanding and addressing health and illness. The biomedical model, historically prevalent, takes a reductionist approach by focusing on biological factors and treating diseases through medical interventions.^[23] In contrast, the biopsychosocial model adopts a holistic viewpoint, acknowledging the complex interplay of biological, psychological, and social factors in shaping health and illness.^[23] Unlike the biomedical model, which sees diseases as isolated physical abnormalities, the biopsychosocial model views them as outcomes of dynamic interactions among various dimensions. Treatment under the biopsychosocial model is comprehensive, involving medical, psychological, and social interventions to address overall well-being.^[24] This model emphasizes the interconnectedness of these dimensions, recognizing their mutual influence on an individual's health.^[24]

In the last decade, there has been a rising interest among healthcare researchers and practicing medical professionals in the biopsychosocial model.^[4] However, despite the rising interest, medical schools have had limited use of the model in their curriculums relative to the increasing literature about the model.^[25]

The biopsychosocial model is still widely used as both a philosophy of clinical care and a practical clinical guide useful for broadening the scope of a clinician's gaze.^[26] Borrell-Carrió and colleagues reviewed Engel's model 25 years on.^[26] They proposed the model had evolved into a biopsychosocial and relationship-centered framework for physicians. They proposed three clarifications to the model, and identified seven established principles.

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.
7. Communicating clinical evidence to foster dialogue, not just the mechanical application of protocol.

Gatchel and colleagues argued in 2007 the biopsychosocial model is the most widely accepted as the most heuristic approach to understanding and treating chronic pain.^[27]

Other theorists and researchers are using the term biopsychosocial, or sometimes bio-psycho-social to distinguish Engel's model.^[3]

Lumley and colleagues used a non-Engel model to conduct a biopsychosocial assessment of the relationship between and pain and emotion.^[28] Zucker and Gomberg used a non-Engel biopsychosocial perspective to assess the etiology of alcoholism in 1986.^[29]

Crittenden considers the Dynamic-Maturational Model of Attachment and Adaptation (DMM), to be a biopsychosocial model.^[3][30] It incorporates many disciplines to understand human development and information processing.^[31]

Kozlowska's Functional Somatic Symptoms model uses a biopsychosocial approach to understand somatic symptoms.^[32][33] Siegel's Interpersonal Neurobiology (IPNB) model is similar, although, perhaps to distinguish IPNB from Engel's model, he describes how the brain, mind, and relationships are part of one reality rather three separate elements.^[34] Most trauma informed care models are biopsychosocial models.^[35][36]

Wickrama and colleagues have conducted several biopsychosocial-based studies examining marital dynamics. In a longitudinal study of women divorced midlife they found that divorce contributed to an adverse biopsychosocial process for the women.^[37] In another study of enduring marriages, they looked to see if hostile marital interactions in the early middle years could wear down couples regulator systems through greater psychological distress, more health-risk behaviors, and a higher body mass index (BMI). Their findings confirmed negative outcomes and increased vulnerability to later physical health problems for both husbands and wives.^[38]

Kovacs and colleagues meta-study examined the biopsychosocial experiences of adults with congenital heart disease.^[39] Zhang and colleagues used a biopsychosocial approach to examine parents own physiological response when facing children's negative emotions, and how it related to parents’ ability to engage in sensitive and supportive behaviors.^[40] They found parents’ physiological regulatory functioning was an important factor in shaping parenting behaviors directed toward children's emotions.

A biopsychosocial approach was used to assess race and ethnic differences in aging and to develop the Michigan Cognitive Aging Project.^[41] Banerjee and colleagues used a biopsychosocial narrative to describe the dual pandemic of suicide and COVID-19.^[42]

When Engel first proposed the biopsychosocial model it was for the purpose of better understanding health and illness. While this application still holds true the model is relevant to topics such as health, medicine, and development. Firstly, as proposed by Engel, it helps physicians better understand their whole patient. Considering not only physiological and medical aspects but also psychological and sociological well-being.^[26] Furthermore, this model is closely tied to health psychology. Health psychology examines the reciprocal influences of biology, psychology, behavioral, and social factors on health and illness.

One application of the biopsychosocial model within health and medicine relates to pain, such that several factors outside an individual's health may affect their perception of pain. For example, a 2019 study linked genetic and biopsychosocial factors to increased post-operative shoulder pain.^[43] Future studies are needed to model and further explore the relationship between biopsychosocial factors and pain.^[44]

The developmental applications of this model are equally relevant. One particular advantage of applying the biopsychosocial model to developmental psychology is that it allows for an intersection within the nature versus nurture debate. This model provides developmental psychologists a theoretical basis for the interplay of both hereditary and psychosocial factors on an individual's development.^[26]

Within the framework of the biopsychosocial model, gender is regarded by some as a complex and nuanced construct, shaped by the intricate interplay of social, psychological, and biological factors.^[45] This perspective, as echoed by the Gender Spectrum Organization, defines gender as the multifaceted interrelationship between three key dimensions: body, identity, and social gender.^[46] In essence, this characterization aligns with the fundamental principles of the biopsychosocial model, emphasizing the need to consider not only biological determinants but also the profound influences of psychological and social contexts on the formation of gender.^[45][47]

According to the insights of Alex Iantaffi and Meg-John Barker, the biopsychosocial model provides a comprehensive framework to understand the complexities of gender.^[45] They illustrate that biological, psychological, and social factors are not isolated entities but rather intricately intertwined elements that continually interact and shape one another. In this dynamic process, a person's gender identity emerges as the result of a complex interplay between their biological characteristics, psychological experiences, and social interactions.^[45] This holistic perspective is in harmony with the biopsychosocial model's approach, which acknowledges the inseparable connection between these various dimensions in influencing an individual's overall well-being.

In essence, within the biopsychosocial paradigm, gender is not merely a product of biological determinants; rather, it is a dynamic and interconnected aspect of human identity.^[1][45] This perspective urges a more nuanced understanding, encouraging researchers and medical professionals to consider the intricate interplay of social, psychological, and biological factors when exploring and addressing the complexities of gender.^[1]

There have been a number of criticisms of Engel's biopsychosocial model.^[48][49][50] Benning summarized the arguments against the model including that it lacked philosophical coherence, was insensitive to patients' subjective experience, was unfaithful to the general systems theory that Engel claimed it be rooted in, and that it engendered an undisciplined eclecticism that provides no safeguards against either the dominance or the under-representation of any one of the three domains of bio, psycho, or social.^[51]

Psychiatrist Hamid Tavakoli argues that Engel's biopsychosocial 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 de-stigmatize mental health.^[52] The perspectives model does not make that arbitrary distinction.^[53]

A number of these criticisms have been addressed over recent years. For example, the biopsychosocial pathways model describes how it is possible to conceptually separate, define, and measure biological, psychological, and social factors, and thereby seek detailed interrelationships among these factors.^[54]

While Engel's call to arms for a biopsychosocial model has been taken up in several healthcare fields and developed in related models, it has not been adopted in acute medical and surgical domains, as of 2017.^[6]