The Biopsychosocial Model 40 Years On

Abstract

The first chapter outlines George Engel's proposal of a new biopsychosocial model for medicine and healthcare in papers 40 years ago and reviews its current status. The model is popular and much invoked in clinical and health education settings and has claim to be the overarching framework for contemporary healthcare. On the other hand, the model has been increasingly criticised for being vague, useless, and even incoherent-clinically, scientifically and philosophically. The combination of these two points signifies something of a crisis in the conceptual foundations of medicine and healthcare. We outline some of the emerging evidence implicating psychosocial as well as biological factors in health and disease, and propose the following solution to the vagueness problem: that the scientific and clinical content of the model relates to specific conditions and stages of conditions, so that there is, for example, a biopsychosocial model of cardiovascular disease, diabetes or depression. Much the same point applies to the narrower biomedical model. However this raises the question: what is the point of having a general model? Our response is that it is needed to theorise biopsychosocial interactions in health and disease. In the light of historical prejudices against psychosocial causation deriving from physicalist reductionism and dualism, recognised by Engel and current commentators on the biopsychosocial model, this is a non-trivial task that occupies subsequent chapters. Engel's Proposed Improvement on the Biomedical ModelIn his classic paper published in 1977 George Engel proposed a new model for medicine, the biopsychosocial model, contrasted with the existing biomedical model [1]. While recognising the great advances in biomedicine, Engel argued that nevertheless the biomedical model was limited, and insufficient for many aspects of medical science and healthcare. These limitations were extensive, comprising failure to take account of the following: the person who has the illness, the person's experience of, account of and attitude towards the illness; whether the person or others in fact regard the condition as an illness; care of the patient as a person; for some conditions such as schizophrenia and diabetes, the effect of conditions of living on onset, presentation and course; and finally, the healthcare system itself also cannot be conceptualised solely in biomedical terms but rather involves social factors such as professionalisation ([1], pp. 131-135). Engel argued that a broadening of the biomedical approach, a new biopsychosocial model, was needed to take account of all these factors 'contributing to both illness and patienthood' ([1], p. 133). The Presumed 'Overarching Framework'In his review of a recent book on the biopsychosocial model by Nassir Ghaemi [2], in The American Journal of Psychiatry, Kenneth Kendler starts with the sentence: "This book is about a very important topicthe overarching conceptual framework of our field of psychiatry" ([3], p. 999).Whether the biopsychosocial model has this s...

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