The biopsychosocial model: Its use and abuse 2023 Roberts

Abstract

The biopsychosocial model (BPSM) is increasingly influential in medical research and practice. Several philosophers and scholars of health have criticized the BPSM for lacking meaningful scientific content. This article extends those critiques by showing how the BPSM’s epistemic weaknesses have led to certain problems in medical discourse. Despite its lack of content, many researchers have mistaken the BPSM for a scientific model with explanatory power. This misapprehension has placed researchers in an implicit bind. There is an expectation that applications of the BPSM will deliver insights about disease; yet the model offers no tools for producing valid (or probabilistically true) knowledge claims.

I argue that many researchers have, unwittingly, responded to this predicament by developing certain patterns of specious argumentation I call “wayward BPSM discourse.” The arguments of wayward discourse share a common form: They appear to deliver insights about disease gleaned through applications of the BPSM; on closer inspection, however, we find that the putative conclusions presented are actually assertions resting on question-begging arguments, appeals to authority, and conceptual errors. Through several case studies of BPSM articles and literatures, this article describes wayward discourse and its effects. Wayward discourse has introduced into medicine forms of conceptual instability that threaten to undermine various lines of research. It has also created a potentially potent vector of medicalization. Fixing these problems will likely require reimposing conceptual rigor on BPSM discourse.

Open access, https://link.springer.com/article/10.1007/s11019-023-10150-2

 

References to 'CFS' :

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 168 KB)


From that file:

Chronic Fatigue Syndrome

[...]

 

This is a joy to read. It’s proper applied philosophy, directed shrewdly at the weakest points of the BPS epistemic structure.

I don’t think that Roberts’ validity attack on diseases which are named and identified in question-begging BPS terms necessarily prevents us from naming common clusters of symptoms as a syndrome, or even as a disease: it just stops us from ascribing consequences to the syndrome itself. So as far as I can see, there’s nothing in the argument which risks throwing useful diagnostic babies out with the bathwater.

 

There are some interesting paragraphs in this paper, for example:

"What the BPSM is, then, is essentially the general proposition that illness involves biological, psychological, and social factors [...] The model’s three domains include more or less everything that impacts human life. The BPSM simply posits that when people fall ill, it is because some subset of all possible causal factors somehow interacted to make them ill. The model is thus vague, all-inclusive, and lacks meaningful scientific content. Essentially the BPSM states a truism about illness."
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But the rest of the article mainly focuses on the critique that the BPS model blurs the distinction between “disease” (an objectivelyverifiable disruption of the body) and “illness” (subjective malaise and impairment of the person).

The author discusses TMD and IBS as examples, CFS is mentioned in the appendix. I suspect he thinks it is unexplained fatigue and that it is inappropriate to medicalise this etc.

 

The frustrating thing is that so few authors consider the possibility that there are diseases who's pathology have not yet been discovered due to limitations in our current medical understanding.

 

But surely it’s still in our interest for the BPS construction of CFS (as unexplained fatigue partly resulting from psychosocial triggers) to be delegitimised. It doesn’t really matter whether Roberts knows anything about PEM.

 

Roberts relies to some extent on that distinction, partly because it’s an acknowledged critique of the BPS model, but his novel line of attack is that the BPS model is not actually a model, and therefore cannot be adduced in any non-circular discussion of clinical cause and effect.

 

This is a good assessment of the BPS model, but it also reveals why critiques of it have to be properly thought out—otherwise you'll be denying something that probably is true to some degree.

 

Generally, I see the BPS model as the simple application of "because I say so". It does not bother with validity, it doesn't need to, because in the end it always follows the same formula: "you feel X, but actually it's YZ, because I say so".

It's actually a regressive model in that it's significantly worse than no model at all, in pretty much every single way, the most significant of which has been the complete end of all progress in many areas of medicine. It's no exaggeration that medicine is just as awful at dealing with chronic illness than it was at the time when Freud started making this stuff up.

Nothing's changed, except now the failure is entirely locked in place because the BPS model is circular, and considers failure to be the same as success. Society has changed because of technological progress. The Internet alone has done more to improve our lives than everything medicine did, combined. But medical care is still stuck in the mid-19th century, ugly prejudices and all.

It doesn't really do anything beyond giving physicians a free "get out of my office" card with unlimited uses. That's all it ever was about: can't help everyone, can't admit to this, so kick as many people out as possible and focus on what feels rewarding. Even though I can hardly think of a more rewarding thing in medicine than giving tens of millions of people back their lives.

Being able to so dramatically change people's lives in ways that didn't exist before has become rarer and rarer, in large part thanks to the BPS model. So it's ironic that the thing physicians crave the most is completely blocked by their own making, entirely out of a completely defeatist attitude (why bother trying if we're going to fail anyway?), which they then project entirely on us.

The BPS model is basically the medical equivalent of bringing back corporal punishment in education: doesn't solve any problem, never had a reason to exist in the first place, is clearly unethical, but boy do some people love to give a good paddling and so they go.

 

If two diametrically opposed sides (CFS is overmedicalized fatigue vs CFS is a real disease) share the same assessment and conclusions about the biopsychosocial model, surely this ought to mean that the critique is valid?

 

It is a rhetorical device. But one which is like catnip to silly laypersons who are half-listening or tend to summarise-listen where they basically don't listen and then just wait for the one sentence they half-understand whilst they are thinking of what they are going to say. Like someone writing an article saying education is good.

It is also worse than that because there is switch-and-bait underneath it as to which direction these vectors should be in and whether they are positive or negative

So you end up with basically sophist arguing back as someone switches from generalist category-based assertions vs specifics.

In essence if you were trying to argue with someone who doesn't know how to think properly on one of these articles on BPSM then you can't: because they've set it up for different readers to be holding different concepts to which they are talking.

Of course at the moment my current pat-hate and give-away in others is when they say 'but isn't CBT a good thing and helpful' and then try and switch off and not listen when I try and explain what a misnomer they've just said because basically CBT is a delivery-mechanism like a cassette-tape or a CD. Without focusing instead on what on earth is on the blinking thing. It could be the exact opposite of what someone actually needs and would be good for their issue.

 

This is the section where I start to disagree with this article.

I would say, and have always thought quite the opposite. Without seeking to thoroughly investigate the potential pathways in their entireity e.g. by looking at all factors (not just the 'fear and thinking' ones that are often simply invented or assumed) and NOT doing it by epidemiology but weighting and proper models the whole thing is just an open concept for people working in very insular areas, recruiting from very insular backgrounds in the first place to sadly foster problem thinking and bigotries. I do not think they will get these out without them being picked up by people as such and spelled out to them as awful assumptions they shouldn't dare to make of others.

I'd have no issue if someone instead took a very specific disease e.g. diabetes and then narrowed down each of those social factors - particularly as ENgel wanted the status and financial - and put them into a model where there was causation and interaction to show how e.g. changing access to good food easily (convenience of access, price) could 'unlock' good for all sorts of aspects of their lives.

I actually think that defining 'disease' or 'injury' in the more specific as a model would have made this more valid given that we know there is environment + genes in different proportions not just for different diseases but specific genes e.g. BRCA vs asbestosis

I'm also not completely sure about some of the things thrown in there to 'muddy' that simply can't be well assessed in the current flawed medical system. who has the false belief out of the clinician vs the patient in a 20min medical encounter would actually be impossible to accurately determine, yet any difference would be assume to be in the direction of the power relationship. Which up-plays the error value coming from those subject areas that are shot as far as credibility and science (basing everything on dodgy associations that themselves might have been assessed by an outsider with poor insight and conflict of interest or bias). Hence easily building innate bigotries into a model by calling it 'conceptual' and not every testing these properly under the same scrutiny as all the 'factors' that might be properly measured.

I really don't fully understand, as someone with a scientific psychology background, where on earth the predominance and presumption of 'attributions and beliefs' being seen as the bulk cause behind everything come from other than a bigotry towards others from different demographic groups. Particularly when the beliefs and values of the groups doing the judging have so often been proven to be very wrong indeed and yet still never corrected.

It has also shown how 'hidebound' a profession can be to limiting what it will consider on that list in how it has dealt with ME/CFS, the 2-day CPET findings and tbh the decades of decent indications regarding exertion impact from pacing. A computer programme could easily have inputted thousands of people's worth of detailed individual personal experiments on the impact of exercise and effects days later and e.g. noise, cognition, work, shower, rest vs 'wellness' to have come up with a much more scientific modelled conclusion on the condition that would have been the opposite to one reliant only on 'fear and beliefs'. I don't get the 'science' quite simply of having 'attributions' without having the actual 'association' tested to test those attributions as being incorrect.

Surely just as the profession should have been able to do an audit realising what their incorrect beliefs and information and push regarding e.g. sugar vs fat might have done because they didn't have a model where they could even unpick what that red herring did they should be pretty embarrassed if they had humility. Or any of the scandals like vaginal mesh for its cascading impacts. They could easily have mapped how updating this to the correct information 'turned around' each of these interacting factors if they believed in that so much. But as a 'conceptual model' those 'inbuilt beliefs' were left unaccountable.

There also seems to be little 'individual' on the patient end from the model as it is currently used, merely stereotypes that sadly are up-weighted and up-rated against demographics, simply because of 'attributions' from clinicians based on bias and lack of abiity to understand or take the word of someone on their lifestyle or living.

The less you seek to define 'disease' the more all the model is really doing is defining 'heuristics', or bigotries, at best 'convenient assumptions' of the professions itself. It has been allowed to be easier to write 'must be fearful or stressed' (without knowing the meaning of that word) requiring no evidence or specificity or indeed expertise than to tick any of the other boxes which are 'discrete' ie you can't make up. Although even where information exists e.g. tests that might explain much of someone's model the dodgy attributions overtake and can cause that to either be removed or 'assumed to be because patient lied about taking medication'. So it undermines even the 'knowns'. In an area where as we all know research of what they do know was far from making sure that they had demographically representative samples. So theoretically anyone not a white man with whatever demographic is likely to sign up for trials suddenly becomes pathologised for not having the same tests, health or situation as those white men with whatever their status and living situation is - and it be explained away in assumption of 'their thinking' potentially.

 

Random thought, but a good name for this could be Lorem ipsum medicine, or Lorem ipsum healthcare.

Lorem ipsum is some text that for some reason the typographic industry has used for a long time as a placeholder text. It's still commonly used in design, wherever text should go, Lorem ipsum is just used as placeholder, indicating "here will be text, but this text isn't meant to be read, simply to graphically illustrate what text here would look like".

It's meant to mean nothing. It's devoid of substance since most people don't know what it means, and it's not important anyway. But it is used a lot. Because it's convenient, just as convenient as writing down an entire life because Lorem ipsum... As long as one doesn't care about outcomes. Or ethics. Or professional duty.

Which is the psychosomatic way. Always have been. Always will be. This ideology is as rotten to the core as any other form of bigotry.