The biopsychosocial model

Indigophoton

Indigophoton

Senior Member (Voting Rights)
Lancet 'Insight': In defence of the biopsychosocial model

A short piece. It's not much of a defence.
It is now 40 years since George Engel, a psychiatrist from the University of Rochester, New York, NY, USA, put forward his idea of the biopsychosocial model. Engel argued that if psychiatry aimed to generate a fully scientific and inclusive account of mental disorder, then bioreductionist accounts should be superseded by a new model that adhered to the insights of the General Systems Theory (first proposed by Ludwig von Bertalanffy in 1937 as a scientific approach for the study of whole systems and their component parts). Mental health problems, said Engel, like other types of medical problems, emerge within individuals who are part of a whole system: with both sub-personal physical elements (the nervous system) and supra-personal or psychosocial elements (one-to-one relationships, family, community, society).
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Engel, who had a major interest in psychosomatic medicine, used case studies of people with primarily physical diagnoses such as coronary heart disease in his original papers). Clare argued vehemently that the true medical model is not a biomedical one, but biopsychosocial; a statement that still bears repeating decades later. His exposition of the importance of the model in investigating the cause of the patient's problems, understanding the aetiology, and synthesising these elements into a formulation and a multifaceted plan for treatment, helped me to appreciate one of the essential skills of psychiatry. That is, having the ability, knowledge, and flexibility of attitude to switch between the three different lenses of biology, psychology, and social science; and being capable of sharing, negotiating, and planning with the patient which of these approaches—or combination of them—seems to be optimal for this individual presenting with this problem at this point in time.
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(emphasis added)
We should build our care plan around the needs and wishes of the patient, not the clinician's theoretical preferences.
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If only.
Despite its longevity there has been no shortage of critics of the model since Engel first described it. ... In his book The rise and fall of the biopsychosocial model (2010), the American psychiatrist Nassir Ghaemi went further in his condemnation, arguing that it “rose from the ashes of psychoanalysis and is dying on shoals of neurobiology”.
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I liked that bit.

http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(18)30165-2/fulltext
 
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I don't think it needs a whole article to rebut it. The basic argument is:
Engel reminded us that the value of a scientific model should be measured not by whether it is right or wrong, but how useful it is. ... if we consider Engel's point about value, his model still has tremendous practical utility both in research and clinical work and it encourages us to be flexible, not dogmatic, in our work.
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Leaving aside the fact that the application of the BPS model to ME disproves this contention (it has not been useful, quite the opposite, and they have been inflexible and very dogmatic), this argument suggests a lack of understanding of science. Finding out whether a model is right or wrong, disproven or supported by the evidence, is essential. The Higgs boson, for instance, with all its implications, had to be found to become genuinely useful.

BPS haven't even put forward testable hypotheses, as far as I know. We could take PACE as a test of the model - they did say that was a test of their philosophy, after all - and it failed.
 
"Engel reminded us that the value of a scientific model should be measured not by whether it is right or wrong, but how useful it is".

I can accept that usefulness can sometimes become apparent long before some theory is proven to be right or not, but in that instance it is most certainly not a scientific model! And I find it hard to see how a scientist could say that.

Back in history metal workers found that they could work iron in ways to make it much stronger that just the raw iron. They did not understand the science of heat treatments, nor did they necessarily realise that the carbon content in their furnaces was actually turning the iron into a steel alloy. But the good artisans would have developed their own methods, possibly developing on empirical skills honed through generations. In a sense they had evolved an empirical model that was extremely useful ... but it was not a scientific model.
 
Barry said:
In a sense they had evolved an empirical model that was extremely useful ... but it was not a scientific model.
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I don't think a model is necessary for it to be science though. Careful empirical observation is the stuff that should inform the development of a model or hypothesis and is part of the scientific process. So is an untested hypothesis since it informs what evidence should be collected to confirm or deny it. But accepting a hypothesis as useful without any supporting evidence - now that's not science.
 
I prefer the idea of a biosocial model. Consider the person's social/environmental situation, and if its not optimal for health (e.g. damp house, loneliness, can 't get access to fresh food, living with addicts), support the person to change it.

To me, the psychological is just an emergent property of the interaction between environment (social, etc) and biology. You deal with those two, you've got it covered.

Its kind of crazy the way we think the psyche can somehow operate independently of environment and biology - that people can think themselves out of depression, illness, etc. You change the body or the environment (whichever is most implicated), the psyche will follow.
 
I'd prefer if they stayed the hell away from sociological models/texts because they can't even understand the basic foundations of Structural Functionalism. I think it appealed to them because it contained the concept of deviance, and they put a moral value on the deviance.

The concept of deviance (imho) was/is value neutral, just a measuring of things that are not part of the norm. In most cases the society adjusts over time to accept the deviance and include it inside the norm. That was part of the point of studying the deviances in the first place, to see how and why this happens. To study how societies adapt and evolve to include what was once not included, and to observe how this contributes to social cohesion.

In the BPS case, they have decided that our deviance is immoral, and done their best to create structures and institutions that deny us access to being included, right down to basic social necessities like food, shelter, income and services. If they understood the basics of their own supposed theories, they would understand how this is likely to be unsuccessful over time, just like it was in our societies treatment of women voting, acceptance of homosexuality, various disabilities and illnesses.
 
Bertalanffy's general systems theory is actually unscientific in the wider sense of being untestable. So it is outside even empirical models that are testable and reliable.

Generalsystems theory denies that the dynamics of a system can be predicted from dynamic components. It says that the whole system shows 'emergent properties' that cannot be predicted. It is in this sense anti-scientific and I suspect has never actually been of any value.

There is a lot of bullshit about this. The strange attractor states of chaotic systems are often given as examples. However they are not because they can be modelled with computers that DO generate the overall dynamics from component dynamic relations. If you can run something on a computer it cannot be emergent in GST sense.

As usual it is just muddled thinking.

Again this is an indication of the anti-scientific stance of psychiatry.
 
Engel reminded us that the value of a scientific model should be measured not by whether it is right or wrong, but how useful it is.
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The incredibly "useful," but wrong, Ptolemaic world system was so accurate (it was just as good at matching and predicting observations as the later Copernican system) that it managed to hold science back for 1500 years.

heliocentric-model.jpg
 
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I can't help but think this whole predicament relating to our humble condition is indicative of some sort of fundamental rot in the domains of science.

Too many people in 'scientific' fields are afflicted with a smarmy conceit; their title and status appease vain pretensions to claims of rarefied knowledge and achievement but camouflage a lax dedication to the fundamental tenets of scientific pursuit. Others are more conscientious but perhaps lose heart when confronted with the limitations of our current understandings; not recognizing the grave importance of upholding an honest position of 'we don't know', they fail to mount a vigorous defense of these knowledge 'gaps' against seductive pseudoscientific speculations that seek to establish beachheads upon them.

This leaves these fields prone to excessive endogenous production of stupid ideas and vulnerable to infection via Trojan horse; once established, these misbegotten or malicious ideas can gain vastly greater power and longevity they ever should.
 
James Morris-Lent said:
Too many people in 'scientific' fields are afflicted with a smarmy conceit; their title and status appease vain pretensions to claims of rarefied knowledge and achievement but camouflage a lax dedication to the fundamental tenets of scientific pursuit.
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Some are. Many are concerned about careers and end up following the fashion in research, I suspect in part as that is where the money is. Some who aren't very good at science seem to take up positions in academic or research management and have way too much influence.

Many if not most go into science because they like the challenge of finding out new stuff and solving the hard problems. I think one of things that Ron Davis did well was try to set ME up as a hard problem worth working on. But research costs and money is required for most research.
 
Adrian said:
Some are. Many are concerned about careers and end up following the fashion in research, I suspect in part as that is where the money is. Some who aren't very good at science seem to take up positions in academic or research management and have way too much influence.

Many if not most go into science because they like the challenge of finding out new stuff and solving the hard problems. I think one of things that Ron Davis did well was try to set ME up as a hard problem worth working on. But research costs and money is required for most research.
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Nicely put. I think this structural view is an important complement and qualifier to what I'm trying to articulate. I mean, my perspective is that some people are pretty crummy but most are decent; they're just operating within big forces beyond their control that tend to funnel them into the categories I'm proposing. I'm kind of trying to gear up to write an essay, so hopefully I can marry these two perspectives.
I have no wish to trash people who don't deserve it.
 
Lucibee said:
The main flaw with the biopsychosocial model is that it can be moulded to serve any agenda.
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A warning sign for snake-oil is its almost miraculous claim to cure a wide range of unrelated conditions.

Like the Lightning Process, for example.

Woolie said:
To me, the psychological is just an emergent property of the interaction between environment (social, etc) and biology. You deal with those two, you've got it covered.
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I agree. It seems more an end result or outward expression of those two interacting factors. Might be useful as some kind of diagnostic marker, but it's role in causing poorer outcomes (especially long-term) is not so certain.
 
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