The biopsychosocial model

George Engel was deeply into psychosomatic ideology, and it was his career and way of working. What you remember and have been taught is the motte. (I'll try to add a post with some of his beliefs.)

"Biopsychosocial" is a replacement term for psychosomatic; It funnels the views of the psychosomatic movement into medicine without it protesting because it doesn't recognise it and gets pulled in at the entry with a "soft" version. New glossy wrapper, same content. The meaning you describe here is again, the motte.

Based on what I've seen so far I say it always was meant as the psychosomatic monster. Engel certainly meant it that way, despite making it sound palatable, and he was the one boosting the term. (see also my post above.)

I'd say so. The motte is quite sensible and possibly helpful, but the actual meant bailey -viewing all illness through the lens of psychosomatic ideology- is what is meant to be normalized and deemed acceptable in medicine. (I'd also guess that by making people accept the "soft", reasonable-sounding motte "entry", it is then a lot easier to move people's views towards the bailey, especially if you play on their prejudices. Phrases like "taking psychosocial factors into account in illnesses" are a total double-talk dog whistle imo.)

 

"Biopsychosocial" is one of those Janus-faced words, like "functional", but Engel's vision always was a fully psychosomatic one. A freely available PDF of the paper of Engel that started all this, "The Need for a New Medical Model: A Challenge for Biomedicine":

https://www.urmc.rochester.edu/Medi...enge-to-Biomedicine-Biopsychosicial-Model.pdf

And a subsequent 1980 paper by Engel on the application of the biopsychosocial model to a case of myocardial infarction:

https://www.pacesconnection.com/fil...plication of of the biopsychosocial model.pdf

 

Due to the topics I’m pursuing, I’ve collected and read on Engel. I still have to process all the documentation I have into a section on him beyond a first crude, incomplete draft (I’m working my writing way to it at an excruciating snail pace), but I feel confident in saying that that man was absolutely no benign patient ally, and that people are not just misrepresenting his "biopsychosocial model" when they go psychosomatic - the man was a bigwig in the American psychosomatic movement and he ran a psychiatry unit that explicitly worked based on psychosomatic ideology since 1946 (when psychosomatics was still somewhat popular) - he continued working based on those views until at least 1980.

My post is long, so I hid the rest behind a spoiler, but the gyst is that Engel was deeply into psychosomatic ideology, with the classical, prejudiced, theoretical and often downright bizarre beliefs this entailed, and it was his career. I believe his views and writings - which are deeply prejudiced, ignorant, misogynist, disableist (and often batshit)- should not be, nor should ever have been, anywhere near medicine, particularly for women, and this includes the "biopsychosocial model" he wrote about, which is the psychosomatic model.

(That other, likeminded psychiatrists enthusiastically adopted his term "biopsychosocial model" to push the same-old harmful psychosomatic junk in a new wrapper, or that they and Engel themselves were at times able to cloak the meaning in pretty, reasonable-sounding language, says nothing of its quality or applicability to reality.)

Spoiler: Elaboration on Engel's beliefs

I had a bad night, I can’t write well or look up much so I’ll have to rely on rough notes, but Engel was a psychosomatic ideologists to his core and he followed (and taught) the classical, typical beliefs from the American psychosomatic movement. First and foremost that physical illness was the result of psychological processes (in his case particularly patriarchally/conservatively flavoured), but also e.g. what basically boils down to the doctrine of signatures for bodies (conversion of emotions to matching physical symptoms, e.g he taught that people become blind because they do not want someone else to see something, or get pain in a body part because that is where they unconsciously wanted to hit someone else – “Character structure also figures importantly in determining the form that an illness may take.”), the inferior role of pathogens and physical processes as driver of ill health, and antagonism towards medicine as “the biomedical approach” that is regarded inferior and limited compared to their superior and more insightful psychosomatic one.
Engel believed for example that “the tubercle bacillus is a necessary but not sufficient condition for tuberculosis”, and that “the immediate effects of the viable tubercle bacillus account for only a few, not all the clinical manifestations of tuberculosis.” His elaboration on it is very underwhelming, he’s clearly trying to make it fit his preference that pathogens are not the ultimate cause of illness presentation[1], that there must be personal factors involved, in accordance with his psychosomatic and health supremacy views - his ableist personal preference where psychological factors and behaviour are the decisive factor in getting ill .

According to Engel (in 1967, when discussing how to incorporate the psychosomatic approach into medical education): “the role of mind and brain in the regulation of somatic processes and organismal adjustment will prove to be the most important basic discipline to emerge in the second half of the 20th century.” [edited as I first used a slightly different worded 1968 quote by a UK admirer]

A piece from my (still very crude!) draft notes on how illness developed according to Engel:
<<Under the header "patterns of response to psychological stress as factors in determining the manifestations of illness.”, he uses an arsenal of mental gymnastics to make his basically disableist health supremacy notion fit. According to his views, certain people just can’t handle anger, shame, guilt, helplessness & hopelessness like other people can, which, he theorizes, leads to physical changes. Then, in an effort to make the unpleasantness go away, it leads to behaviour exemplary of neuroses (hysteria, hypochondria), perversions (homosexuality, transgenderism, oral and anal sex, frigidity, etc, especially anything that deviated from the patriarchal view of only heterosexual penetrating sex being “normal”) and character disorders. This then “may directly or indirectly expose or predispose the person to other varieties of environmental stress, such as injury, poisons, drugs, dietary deficiency, etc., with all the consequences already mentioned. In other words, the inadequacies or inappropriateness of the person's attempt to deal with this intrapsychic distress may include behaviour which does not properly evaluate or avoid the stresses of the external environment or renders the person incapable to do so.”

So, in your effort and inferior ability to deal with emotions you found unpleasant, you gave into being gay, having oral sex, or being a sick woman etc -the behaviour patriarchal and conservative societies don’t like - or are having a character defect, and these things would then theoretically lead to more risk of exposure to “environmental stress” (injury, poisons, drugs, dietary deficiency etc.), leading to móre hypothesised and undetermined physical changes and “unwanted/inappropriate/deviant behaviour”
And then, “in susceptible individuals”, Engel knits on in his little knitwork of mays, “the biochemical and physiological concomitants of sustained or intense effects may ….directly or indirectly put an already defective system under strain. (e.g., the effect of anxiety or rage on a damaged heart) or accelerate, precipitate, enhance or uncover preexisting, sometimes latent, pathological processes at a biochemical organ or system level (e.g., an infection, neoplasia, diabetes, peptic ulceration, etc.).”

According to Engel’s pet theory, you’re either sick because your (perverted, neurotic) behaviour and emotions in an unspecified way exacerbate physical problems, or because those same things (your defective-deemed “behaviour” and your inferiority to other people in how to handle unpleasant feelings without them causing non-defined physical changes) somehow bippedy bopped boop-cycled you into being more vulnerable to infections, tumor growth, diabetes, ulcers and the whole range of etcetera’s one is willing to apply it to.

This is historically interesting as an example of psychosomatic fantasy-knitting or of how psychiatry is used to spin and push discriminating and harmful narratives about people who do not “behave” according to the wishes of conservative ideology and patriarchy, but it has zero value as a scientific and substantiated distribution of facts, reality and knowledge.>>

He had bizarre views on homosexuality and girls and young women (Heavily based on Freud. Including (and especially) boys-want-to-shag-their-mum, girls-their-dad stuff. And it might just be the Freudian enthusiasm, but when reading I found Engel’s elaborate description of, and obsession with, the supposed sexuality of children not only bad in content but at times even downright creepy.) He confidently taught that “the vagina must eventually replace the clitoris as the primary erotogenic zone”, that when girls discover the anatomical difference between them and males “the first impulse is to want to repudiate the difference and to attempt a masculine identification”, and that “the fantasy of having been deprived of a penis (i.e. castrated) by the mother may occur” which “may engender antagonism toward or fear of the mother” (This was the point where I exclaimed to my partner, “Jeez, has this dude actually ever talked to women, or even met one?” He speaks of them like the Vegetable Lamb of Tartary.)


And I’m just scratching the surface here. An absolutely inappropriate source for medical views.


[1] I have come across this same view in eugenic writing of the 1920s, where it was insinuated that the tuberculosis bacteria was not the sole cause of tuberculosis and the physicians with their bug theory where smirked at as missing the obvious psychiatric influence. Similar in the writings of the psychosomatic movement of the 20’s, 30’s and 1940’s, just before treatment became available.

 

That is not the main intention of Engles.

The "biopsychosocial model" is not really about determinants of health, because it's not a scientific model. It's a model of practise. It was used as a justification for the continued involvement of psychotherapies (and I'm talking about the CBT type rather than the psychoanalytic type) in medicine at a time that psychiatrists' traditional domain was being replaced by pharmacological therapies.