From Engel to Enactivism

Abstract

In this article we offer a two-part commentary on Bolton and Gillett’s reconceptualization of Engel’s biopsychosocial model. In the first section we present a conceptual and historical assessment of the biopsychosocial model that differs from the analysis by Bolton and Gillett. Specifically, we point out that Engel in his vision of the biopsychosocial model was less concerned with the ontological possibility and nature of psychosocial causes, and more concerned with psychosocial influences in the form of illness interpretation and presentation, sick role, seeking or rejection of care, the doctor-patient therapeutic relationship, and role of personality factors and family relationships in recovery from illness, etc. On the basis of this assessment, we then question Bolton and Gillett’s restricted focus on accounting for biopsychosocial causal interactions. The second section compares Bolton and Gillett’s account with a recent enactivist account of mental disorder that tackles similar conceptual problems of causal interactions. Bolton and Gillett’s utilize elements of the 4E cognition, but they combine these proto-ideas with an information-processing paradigm. Given their explicit endorsement of 4E approaches to mind and cognition, we illustrate some key ways in which a more fleshed out enactive account, particularly one that doesn’t rely on notions of information-processing, differs from the account proposed by Bolton and Gillett.

The biopsychosocial model is lost in translation: from misrepresentation to an enactive modernization

“…Subsequent to the work of Borrell-Carrio ( 2004) and many others (Aftab and Nielsen, 2021;Bolton and Gillett, 2019;Buetow, 2021;Coninx and Stilwell, 2021;de Haan, 2020ade Haan, , 2020bde Haan, , 2021Lehman, David, and Gruber, 2017;Low, 2017;Maiese, 2021;Stilwell and Harman, 2019) further emphasized the importance of lived experiences and patients' narratives within the complex, dynamical, interactive, and bi-directional connections across the three BPS domains. A commonality across all of this recent work is the incorporation of enactive theory (Newen, Gallagher, and De Bruin, 2018;Øberg, Normann, and Gallagher, 2015;Thompson, 2004;Varela, Thompson, and Rosch, 1991).…”

“…Instead there is an appreciation of the whole embodied person and how interactions in their environment, including other people, enact or bring forth experiences of ourselves and the world (Varela, Thompson, and Rosch, 1991). There are now many strands of enactivism being applied to health conditions and healthcare in general (Aftab and Nielsen, 2021;Coninx and Stilwell, 2021;de Haan, 2020b;Maiese, 2021;Stilwell and Harman, 2019;Toro, Kiverstein, and Rietveld, 2020). Enactivism offers new and interesting ways to think about both human experience and causation.…”

“…We have three objectives: 1) to present an overview of what Engel actually said about the BPSM by focusing on primary sources; 2) outline what other authors and we interpret as prominent versions (interpretations) and misapplications of the BPSM in research and practice; and 3) present an "enactive" modernization of the BPSM. We place a particular emphasis on recent developments in the enactive literature that target gaps and limitations in Engel's original model (Aftab and Nielsen, 2021;Bolton and Gillett, 2019;Buetow, 2021;Coninx and Stilwell, 2021;de Haan, 2020ade Haan, , 2020bde Haan, , 2021Lehman, David, and Gruber, 2017;Low, 2017;Maiese, 2021;Stilwell and Harman, 2019). We argue that an enactive iteration of the BPSM (what we call an "enactive-BPS approach") strengthens and modernizes Engel's BPSM and may help mitigate misapplications.…”

“…Recently authors have critically examined Engel's work, presenting theoretical limitations, expressing concerns regarding the various ways the BPSM has been interpreted and applied, and offering BPSM enhancements (Aftab and Nielsen, 2021;Bolton and Gillett, 2019;Buetow, 2021;Davidsen, Guassora, and Reventlow, 2016;de Haan, 2020bde Haan, , 2021Ghaemi, 2009;Stilwell and Harman, 2019). As a result it has been shown that the BPSM in its application is often biomedicalized, fragmented, and used in reductionist ways, thereby deviating from the original model proposed by Engel. Two useful versions of the BPSM can be identified in the literature.…”

“…Convergence of these versions of the BPSM may be possible through recently proposed "enactive" frameworks that aim to clarify and extend (i.e. modernize) the BPSM (Aftab and Nielsen, 2021;Buetow, 2021;Coninx and Stilwell, 2021;de Haan, 2020ade Haan, , 2020bde Haan, , 2021Maiese, 2021;Stilwell and Harman, 2019). Both Engel's BPSM and enactive frameworks are rooted in systems theory, are anti-dualist and antireductionist, and call for a more comprehensive or "big picture" approach to health conditions and their management.…”