The biopsychosocial model

The development of integrated bio-psycho-social models are a great idea. The problem is that there are no such models. Most research is still heavily siloed into separate bio, social and psych studies and directional relationships remain unproven for any illness or disease.

 

Most professionals have been taught that the "biopsychosocial" model / view is a very good thing; a move away from biological reductionism towards a more holistic view of patients (which is utter nonsense to anyone who knows anything about medical history, but it seems to be a prevalent view these days). I suspect many won't have encountered anyone who objects to it before.

Perhaps we should switch to using "psychobehavioural" rather than "biopsychosocial" to describe the CBT/GET/you're-not-really-ill-you-just-think-you-are model & its interventions and practitioners? It's pretty much a drop-in replacement: psychobehavioural model; psychobehavioural interventions; psychobehavioural practitioners.

 

Given the researchers and clinician we are critical of generally falsely describe themselves as BPS, I try to remember to slip in a qualifier such as ‘mislabelled as biopsychosocial’

 

It isn’t really a model, it’s a conceptual framework at best:

1. No empirical basis, just «this is how I believe things are connected»
2. No framework to prove causality

It’s an opinion piece, really, and everyone accepted it as truth.

 

Spoiler: Comment

I hear you, the situation you describe in your post is very difficult and painful for patients and a demonstration how the hallmark linguistic trickery of the neo-psychosomatic movement isolates patients from possible help from outsiders, making them look like they're overreacting while the movement simultaneously stigmatizes them as unreliable witnesses - it's a total abusive move.

That being said, I think a more correct description would be that there are people who don't understand (nor listen) because they use the motte version of biopsychosocial. Because "biopsychosocial" is used as a motte-and-bailey term.

It was buzzing around somewhat before 1977, but it got "properly" launched and determined by Freudian fanboy and psychosomatic enthousiast George Engel (as "the biopsychosocial model"), and he absolutely meant the bailey of psychobehavioural & psychosomatic with that term. Just because it got sold as meaning the "softer" and in essence ok motte version (in general considering social & socio-economic circumstances, behaviour & mental health as elements influencing life quality and illness management for patients is not a bad thing) does not mean it doesn't actually mean - or isn't actually meant to facilitate the acceptatence of - the hostile-to-the-biomedical-model bailey, psychosomatic ideology, which pseudo-justifies "treatments" like CBT.

So imo it is not a case that bps "should be used" in the motte way, just that a lot of health care workers believe, or say they believe (the motte-and-bailey fallacy can make it seem internally justifiable as well of course), this is what it means.

I have no solution for this situation yet; ideally the two -motte and bailey- will be clearly separated, the motte getting a new term while it is made clear that there's no room for psychosomatic ideology in its definition.

Spoiler: Comment

In communication it might make it clearer that you are discussing the actual, original meaning to people unaware of it being a double-talk term. So it certainly might help in clarity.
Just as long as it is not forgotten that bps is not something else. The CBT industry & psychosomatic ideologists use and will use the term bps, because they know exactly what they mean by it. I think sidestepping the term will not resolve the double-talk issue.

Spoiler: Comment

I do not think they falsely describe themselves as bps, nor that what they call biopsychosocial is mislabelled.

The term stems from their ranks, and they use it like it is meant.

While I have not gotten to the bottom of this specific topic yet, I've collected and read on it a lot, and to me it looks clear so far that the "biopsychosocial model" itself is a smoke-and mirrors vehicle that allows psychiatric involvement in medicine by using a psychosomatic framework. It borrowed from sociology for some new terms to make it all seem fresh and reasonable, and by doing this they neatly obscured the fact to the casual reader that this was actually still the pushing of "psychosomatic medicine" (because that had crashed hard and was very unpopular)- it was basically the same old pushing of old prejudiced psychiatric views on illness (chiefly hysteria, conversion) and attempting to insert psychosomatic ideology into medicine.

Spoiler: Comment

If this is too political, please remove (I use it as illustration), but it's a bit along the lines of saying you are "pro life" or believe in "right to life". If you take the words at direct meaning, that's also just a statement of the obvious, who can be against that? But the people who coined the terms and use it have a very specific meaning in mind, even as the terms could make it seem benign and something it's not. (The difference is that most people are aware of this, instead of being "educated" it just means respect for life and human rights, with extra attention for good maternal health care, while missing that it is actually hard core used -and meant- to promote to deny women abortions, regularly in the most terrible of circumstances, and that this is actually happening to them.)

(Apologies that I'm sidetraking from the thread topic, but I found it important to address this.)

 

I sort-of love this sentence.
(Because I regrettably have the same experience from another angle.)

(I assume you meant "worse"?)

 

But should it ever be used?

The word was presumably invented for political purposes by someone in public health. It has generally been degraded. I am aware of people in public health who think social factors are of critical importance in providing universal health care (and of course they are) but throwing in psycho- betrays a hand-waving approach to the problem to my mind. We are back to political rhetoric (if of sa different flavour) which is not a good tool for sorting out health care needs.

I am even sceptical on the social front. As an example, death rates from Covid-19 could have been, and still could be, greatly reduced by reducing spread. In comparison lab biology beyond vaccine development has been a more or less complete waste of time and of course it was almost certainly lab biology that gave us the pandemic in the first place. But is reducing spread 'social' or is it just as much biology as spike protein binding? It used to be considered just part of the biology. When my mother worked in the UK Central Public Health Laboratory, which dealt with infection monitoring it was not considered a 'social institution'. It was considered biomedical. Nowadays much less effort is put into reducing spread of infection and as much as anything that seems to be because it is considered a 'social' issue and since you are not supposed to interfere with people's rights to their 'social' activities nothing gets done.

 

It was invented by an American psychiatrist in the 1970s:

https://en.wikipedia.org/wiki/George_L._Engel

The original paper was "The Need for a New Medical Model: A Challenge for Biomedicine" (Science, 1977):

https://www.science.org/doi/10.1126/science.847460

 

Abstract
The dominant model of disease today is biomedical, and it leaves no room within its framework for the social, psychological, and behavioral dimensions of illness. A biopsychosocial model is proposed that provides a blueprint for research, a framework for teaching, and a design for action in the real world of health care.

It was a territory grab based on nothing.

Instead of proving its importance, it just claimed importance.

 

Whether it's a term that has outlived its usefulness is a question one can debate. That it is inherently problematic any more than other words that accrue unwanted weight and meanings seems like a real overstatement to me. There is a heavy UK-centric focus in a lot of these linguistic discussions, and folks tend to behave as if their interpretations are universally understood. Words are used differently and have different meanings in differently countries and contexts. When they become un-useful, it's time to consider coming up with new words.

 

But David, given that Engel was in fact a psychiatrist and that his abstract opens with the contentious if not vacuous, and quite clearly psycho-political proclamation it does, was there ever really another meaning beyond the one used by Michael Sharpe and Peter White. Isn't the reality that it was not degraded. It was always like that, just that Engel cleverly wrapped it up in justifications about heart attacks and diabetes. Isn't it perhaps that US health professionals are a bit more sophisticated about hiding the political content of their usage than their UK counterparts, who blurt it out?

Doesn't that abstract show just how inherently problematic the idea has been all along?

 

I was exposed to the concept in nursing school in 1981 as though it was "the answer" to root causes of ill health.

What vexes me is the huge proportion of funding that goes to psychological studies in health and diseases that has little import, is repetitive, and many instances inaccurate.

What I'd like to see happen in the US is that health disparities suffered by minorities (mainly this is the black population at least historically) be addressed with meaningful actions. I'd take the research funding of psychology and fund more outreach, clinics, med school scholarships for Black and Hispanic doctors.

Of course I'd start with a national health service here.

What is the utility of the BPS concept, really. Are patients more listened to, treated with more dignity and respect?

 

I'm talking about how it has been used by clinicians in a similar way "social determinants of health" is used in public health. I haven't read the original abstract and Engel and all the background, so you're certainly more educated than I am on that point. In general, the idea that bio and psycho and social all impact people's health should not be controversial. The idea that there should be a term to encapsulate that understanding or awareness should also not be controversial, and biopsychosocial seems as good as any on that score on its face. If people use it in ways that are unacceptable, as the people we're all criticizing do, that's a separate matter. Perhaps it was always unacceptable. I haven't examined the history. I'm talking about how I see and hear people use it in the US in a very different way than in the UK.

 

Actually, I just read what was in the thread posts - the introduction to the abstract says enough I think.

My point is that, as the neuroscientist Maria Fitzgerald neatly pointed out following Peter Denton White's insistence on ME/CFS being 'biopsychosocial', it is all biological, so the compound term is otiose.

And the idea never was controversial. Engel claimed that there was insufficient focus on social aspects but in the immediately prior half century tuberculosis had been eradicated from Western Europe not because of new drugs (as is often thought) but by enforcement of isolation. Endemic alcoholism had been dealt with by licensing laws. Public health policy revolutionised health standards then because it focused on the fact that what are called 'social' aspects are mediated through physical biological mechanisms. Now we have the opposite. Tuberculosis is rising rapidly despite all the talk of 'social aspects'. My daughter caught tuberculosis from her pupils at school because the problem was treated as 'social' rather than biological. In order not to be socio-politically incorrect the headmistress refused to acknowledge that there was an outbreak at the school. Everyone says how terribly deprived communities are but they are nothing like as deprived as they were in 1920, when the problem was dealt with efficiently.

The overriding health problem now is obesity. That is not a psychosocial problem it is the biological problem of humans having a craving for food and a political system that favours manipulative commercial interests over public health. We don't need a special word for that - it is obvious to everyone.

I may be wrong but my guess is that anyone using the term biopsychosocial is using it for their own particular hot air purposes. In the old days Public Health Laboratories and governments eradicated anew disease every decade. Now they seem to sit about pontificating while life expectancy drops like a stone!

 

That is how I had understood it, but if the guy was a psychiatrist isn't it likely that this was always a clever psychospeak rigmarole for making a psychologising agenda plausible and fundable? It is typical of the psychosocial/liaison psychiatry lobby to sound terribly plausible about these things, bringing in lots of commonplace examples that sound so reasonable at the time. The abstract above indicates that the whole thing was a power grab by misrepresentation. The idea that there was a 'biomedical' model in 1977 that left no room for the sociopolitical aspects of illness is just manipulative crap. I know because dinner table talk in 1977 with my parents, who were in medicine and public health, made it clear that such factors were integral to their practice.

Wikipedia says:
George Libman Engel (December 10, 1913 – November 26, 1999) was an American psychiatrist and internist who, along with his colleague John Romano, was instrumental in developing and teaching psychosomatic medicine at the University of Rochester Medical Center in Rochester, New York

 

Still where things are. Literally hasn't changed one bit since then. It's a solution still searching for a problem it applies to.

The claim is that it's good because it's biopsychosocial. That's it. That's the claim, completely tautological, hell even teleological (it will be good because it will follow those (optional and imaginary) steps). It has no evidence. It is used almost exclusively in evidence-based medicine. Where evidence is irrelevant.

It basically took a problem, rigid models and institutions, and made them even more rigid, thus making the original problem worse, and inventing all new problems.

Most absurdly, it makes claims about things that this model adds and are good, but none of things require such an ideological model. There is no need for a new overarching ideology for physicians to speak to patients like we're human beings. This was a choice never dictated by a biomedical approach but by culture and tradition.