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AbstractThe biopsychosocial model is both a philosophy of clinical care and a practical clinical guide. Philosophically, it is a wayof understanding how suffering, disease, and illness are affected by multiple levels of organization, from the societal tothe molecular. At the practical level, it is a way of understanding the patient’s subjective experience as an essential contributorto accurate diagnosis, health outcomes, and humane care. In this article, we defend the biopsychosocial model as a necessarycontribution to the scientific clinical method, while suggesting 3 clarifications: (1) the relationship between mental andphysical aspects of health is complex—subjective experience depends on but is not reducible to laws of physiology; (2) modelsof circular causality must be tempered by linear approximations when considering treatment options; and (3) promoting a moreparticipatory clinician-patient relationship is in keeping with current Western cultural tendencies, but may not be universallyaccepted.

We propose a biopsychosocial-oriented clinical practice whose pillars include (1) self-awareness; (2) active cultivationof trust; (3) an emotional style characterized by empathic curiosity; (4) self-calibration as a way to reduce bias; (5) educatingthe emotions to assist with diagnosis and forming therapeutic relationships; (6) using informed intuition; and (7) communicatingclinical evidence to foster dialogue, not just the mechanical application of protocol. In conclusion, the value of the biopsychosocialmodel has not been in the discovery of new scientific laws, as the term “new paradigm” would suggest, but rather in guidingparsimonious application of medical knowledge to the needs of each patient.Key Words:.

GEORGE ENGEL’S LEGACYThe late George Engel believed that to understand and respond adequately to patients’ suffering—and to give them a sense ofbeing understood—clinicians must attend simultaneously to the biological, psychological, and social dimensions of illness.He offered a holistic alternative to the prevailing biomedical model that had dominated industrialized societies since themid-20th century. His new model came to be known as the biopsychosocial model. He formulated his model at a time when science itself was evolvingfrom an exclusively analytic, reductionistic, and specialized endeavor to become more contextual and cross-disciplinary., Engel did not deny that the mainstream of biomedical research had fostered important advances in medicine, but he criticizedits excessively narrow (biomedical) focus for leading clinicians to regard patients as objects and for ignoring the possibilitythat the subjective experience of the patient was amenable to scientific study. Engel championed his ideas not only as a scientificproposal, but also as a fundamental ideology that tried to reverse the dehumanization of medicine and disempowerment of patients(Table 1).

His model struck a resonant chord with those sectors of the medical profession that wished to bring more empathy and compassioninto medical practice. DUALISM, REDUCTIONISM, AND THE DETACHED OBSERVERIn advancing the biopsychosocial model, Engel was responding to 3 main strands in medical thinking that he believed were responsiblefor dehumanizing care. First, he criticized the dualistic nature of the biomedical model, with its separation of body andmind (which is popularly, but perhaps inaccurately, traced to Descartes). This conceptualization (further discussed in the supplemental appendix, available online at ) included an implicit privileging of the former as more “real” and therefore more worthy of a scientific clinician’s attention.Engel rejected this view for encouraging physicians to maintain a strict separation between the body-as-machine and the narrativebiography and emotions of the person—to focus on the disease to the exclusion of the person who was suffering—without buildingbridges between the two realms. His research in psychosomatics pointed toward a more integrative view, showing that fear,rage, neglect, and attachment had physiologic and developmental effects on the whole organism.Second, Engel criticized the excessively materialistic and reductionistic orientation of medical thinking. According to theseprinciples, anything that could not be objectively verified and explained at the level of cellular and molecular processeswas ignored or devalued.

The main focus of this criticism—a cold, impersonal, technical, biomedically-oriented style of clinicalpractice—may not have been so much a matter of underlying philosophy, but discomfort with practice that neglected the humandimension of suffering. His seminal 1980 article on the clinical application of the biopsychosocial model examines the case of a man with chest pain whose arrhythmia was precipitated by a lack of caring on the part of his treatingphysician.The third element was the influence of the observer on the observed. Engel understood that one cannot understand a systemfrom the inside without disturbing the system in some way; in other words, in the human dimension, as in the world of particlephysics, one cannot assume a stance of pure objectivity. In that way, Engel provided a rationale for including the human dimensionof the physician and the patient as a legitimate focus for scientific study.Engel’s perspective is contrasted with a so-called monistic or reductionistic view, in which all phenomena could be reducedto smaller parts and understood as molecular interactions. Nor did he endorse a holistic-energetic view, many of whose adherentsespouse a biopsychosocial philosophy; these views hold that all physical phenomena are ephemeral and controllable by the manipulationof healing energies. Rather, in embracing Systems Theory, Engel recognized that mental and social phenomena depended upon but could not necessarily be reduced to (ie, explained interms of) more basic physical phenomena given our current state of knowledge. He endorsed what would now be considered a complexityview, in which different levels of the biopsychosocial hierarchy could interact, but the rules of interaction might not be directlyderived from the rules of the higher and lower rungs of the biopsychosocial ladder.

Rather, they would be considered emergentproperties that would be highly dependent on the persons involved and the initial conditions with which they were presented,much as large weather patterns can depend on initial conditions and small influences. This perspective has guided decades of research seeking to elucidate the nature of these interactions. Complexity and CausalityFew morbid conditions could be interpreted as being of the nature “one microbe, one illness”; rather, there are usually multipleinteracting causes and contributing factors.

Thus, obesity leads to both diabetes and arthritis; both obesity and arthritislimit exercise capacity, adversely affecting blood pressure and cholesterol levels; and all of the above, except perhaps arthritis,contribute to both stroke and coronary artery disease. Some of the effects (depression after a heart attack or stroke) canthen become causal (greater likelihood of a second similar event). Similar observations can be made about predictors of relapsein schizophrenia. These observations set the stage for models of circular causality, which describes how a series of feedbackloops sustain a specific pattern of behavior over time., Complexity science is an attempt to understand these complex recursive and emergent properties of systems and to find interrelated proximal causes that might be changed with the right set of interventions (family support and medicationsfor schizophrenia; depression screening and cholesterol level reduction after a heart attack).

Structural CausalityIn contrast to the circular view, structural causality describes a hierarchy of unidirectional cause-effect relationships—necessarycauses, precipitants, sustaining forces, and associated events. For instance, a necessary cause for tuberculosis is a mycobacterium, precipitants can be a low body temperature, and a sustainingforce a low caloric intake. Complexity science can facilitate understanding of a clinical situation, but most of the timea structural model is what guides practical action. For example, if we think that Mr. J is hypertensive because he consumestoo much salt, has a stressful job, poor social supports, and an overresponsible personality type, following a circular causalmodel, possibly all of these factors are truly contributory to his high blood pressure.

But, when we suggest to him that hetake an antihypertensive medication, or that he consume less salt, or that he take a stress-reduction course, or that he seea psychotherapist to reduce his sense of guilt, we are creating an implicit hierarchy of causes: Which cause has the greatestlikely contribution to his high blood pressure? Which would be most responsive to our actions? What is the added value ofthis action, after having done others? Which strategy will give the greatest result with the least harm and with the leastexpenditure of resources?

Interpretations, Language, and CausalityCausal attributions have the power to create reality and transform the patient’s view of his/her own world. A physician who listens well might agree when a patient worries that a family argument precipitated a myocardial infarction;although this interpretation may have meaning to the patient, it is inadequate as a total explanation of why the patient suffereda myocardial infarction. The attribution of causality can be used to blame the patient for his or her illness (“If only hehad not smoked so much.”), and also may have the power of suggestion and might actually worsen the patient’s condition (“Everytime there is a fight, your dizziness worsens, don’t you see?”).

Power and Emotions in the Clinical RelationshipPatient-centered, relationship-centered, and client-centered approaches, propose that arriving at a correct biomedical diagnosis is only part of the clinician’s task; they also insist on interpretingillness and health from an intersubjective perspective by giving the patient space to articulate his or her concerns, findingout about the patient’s expectations, and exhorting the health professional to show the patient a human face. These approachesrepresent movement toward an egalitarian relationship in which the clinician is aware of and careful with his or her use ofpower.This “dialogic” model suggests that the reality of each person is not just interpreted by the physician, but actually createdand recreated through dialogue,; individual identities are constructed in and maintained through social interaction. The physician’s task is to come to some shared understanding of the patient’s narrative with the patient. Such understanding does not imply uncritical acceptance of whatever the patient believes or hypothesizes, butneither does it allow for the uncritical negation of the patient’s perspective, as so frequently occurs, for example, whenpatients complain of symptoms that physicians cannot explain.

Biopsychosocial

The patient’s story is simultaneously a statement about the patient’s life, the here-and-now enactment of his life trajectory,and data upon which to formulate a diagnosis and treatment plan.Underlying the analysis of power in the clinical relationship is the issue of how the clinician handles the strong emotionsthat characterize everyday practice. On the one hand, there is a reactive clinical style, in which the clinician reacts swiftlyto expressions of hostility or distrust with denial or suppression. In contrast, a proactive clinical style, characterizedby a mindful openness to experience, might lead the clinician to accept the patient’s expressions with aplomb, using the negativefeelings to strengthen the patient-clinician relationship.

The clinician must acknowledge and then transcend the tendency to label patients as “those with whom I get along well” or“difficult patients.” By removing this set of judgments, true empathy can devolve from a sense of solidarity with the patientand respect for his or her humanity, leading to tolerance and understanding. Thus, in addition to the moral imperative to treat the patient as a person, there is a corresponding imperative for the physicianto care for and deepen knowledge of himself or herself. Without a sufficient degree of self-understanding, it is easy for the physician to confuse empathy with the projection ofhis or her needs onto the patient. Implications for AutonomyMost patients desire more information from their physicians, fewer desire direct participation in clinical decisions, andvery few want to make important decisions without the physician’s advice and consultation with their family members., This does not mean that patients wish to be passive, even the seriously ill and the elderly.

In some cases, however, clinicians unwittingly impose autonomy on patients. Making a reluctant patient assume too much of the burden of knowledge about an illness and decision making, without the advicefrom the physician and support from his or her family, can leave the patient feeling abandoned and deprived of the physician’sjudgment and expertise. The ideal, then, might be “autonomy in relation”—an informed choice supported by a caring relationship. The clinician can offer the patient the option of autonomy while considering the possibility that the patient might not want to know the whole truth and wish to exercise the rightto delegate decisions to family members. The Social MilieuThere is an ecological dimension of each encounter—it is not just between patient and physician, but rather an expressionof social norms. Sometimes clinicians face a dilemma: can or should a private clinical relationship between patient and physician be a vehiclefor social transformation?

Or, should the relationship honor and conform to the cultural norms of patients? Our view is that adaptation normally should occur before transformation—the physician must first understand and accommodateto the patient’s values and cultural norms before trying to effect change. Otherwise, the relationship becomes a politicalbattleground and the focus of a process to which the patient has not consented and may not desire. This debate, however, becomesmuch more difficult in situations in which patients have suffered abuse—for example domestic violence or victims of torture. In those cases, not trying to remedy the social injustices that resulted in the patient seeking care may interfere with theformation of a trusting relationship. The physician may be tempted to effect a social transformation in these cases, for example,to advise the patient to leave an abusive situation, even though the patient may state that she only wants care for the bruises.Premature advice may interfere with enabling the patient to be the agent of change, however.

Stopping short of attemptingto transform social relationships until the patient has given consent should not be interpreted as indifference to, acceptanceof, or complicity in such situations; rather, it should be viewed as a prudent course of action that will ultimately be validatingand empowering. Caring, Paternalism, and EmpathyTaking Engel’s view, perhaps it is not paternalism that is the problem but practicing as a cold technician rather than a caringhealer. The physician who sees his or her role as nothing more than a technical adviser can regard empathy as a useless effort thathas no influence on clinical decisions, or, worse, a set of linguistic tricks to get the patient to comply with treatment.Because it is entirely possible to advocate for shared decision making without challenging the notion of the cold technician,we propose to move the emphasis to an approach that emphasizes human warmth, understanding, generosity, and caring. THE BIOPSYCHOSOCIAL MODEL AND RELATIONSHIP-CENTERED CAREThe practical application of the biopsychosocial model, which we will call biopsychosocially oriented clinical practice does not necessarily evolve from the constructs of interactional dualism or circular causality. Rather, it may be that thecontent and emotions that constitute the clinician’s relationship with the patient are the fundamental principles of biopsychosocial-orientedclinical practice, which then inform the manner in which the physician exercises his or her power. The models of relationshipthat have tended to appear in the medical literature, with a few notable exceptions, have perhaps focused too much on an analysis of power and too little on the underlying emotional climate of the clinicalrelationship.

For this reason, we suggest a reformulation of some of the basic principles of the biopsychosocial model accordingto the emotional tone that engraves the relationship with such characteristics as caring, trustworthiness, and openness. Some principles of biopsychosocial-oriented clinical practice are outlined below.

Calibrating the PhysicianThe biopsychosocial model calls for expanding the number and types of habits to be consciously learned and objectively monitoredto maintain the centrality of the patient. The physician is in some ways like a musical instrument that needs to be calibrated, tuned, and adjusted to perform adequately. The physician’s skills should be judged on their ability to produce greater health or to relieve the patient’s suffering—whetherthey include creating an adequate emotional tone, gathering an accurate history, or distinguishing between what the patientneeds and what the patient says he or she wants.

In that regard, a clinical skill includes the ethical mandate not only tofind out what concerns the patient, but to bring the physician’s agenda to the table and influence the patient’s behavior.Sometimes doing so may include uncovering psychosocial correlates of otherwise unexplained somatic symptoms (such as ongoingabuse or alcoholism) to break the cycle of medicalization and iatrogenesis. To abandon this obligation, in our view, is breaking an implicit social contract between physicians and society. This deliberativeand sometimes frankly physician-centered approach has its perils, however.

The physician must be capable of an ongoing self-auditsimply because his or her performance is never the same from moment to moment. Weick and Sutcliffe regard this constant vigilance as a fundamental requirement for professions that require high reliability in the face ofunexpected events. Mindfulness—the habits of attentive observation, critical curiosity, informed flexibility, and presence—underliesthe physician’s ability to self-monitor, be vigilant, and respond with compassion. Creating TrustThe expert clinician considers explicitly, as a core skill, the achievement in the encounter of an emotional tone conduciveto a therapeutic relationship. For that reason, all consultations might be judged on the basis of cordiality, optimism, genuineness,and good humor.

The Biopsychosocial Model

By receiving a hostile patient with respect, it clarifies for the clinician that the patient’s emotions are the patient’s—and not the physician’s—and also sets the stagefor the patient to reflect as well. Similarly, the physician must know how to recognize and when to express his or her ownemotions, sometimes setting limits and boundaries in the interest of preserving a functional relationship. Recognizing BiasThe grounding of medical decisions based on scientific evidence while also integrating the clinician’s professional experienceis now a well-accepted tenet of the founders of the evidence-based medicine movement.

The method for incorporation of experience, however, has been less well described than the method for judging the qualityof scientific evidence. For example, clinicians should learn how their decisions might be biased by the race and sex of thepatient, among other factors, and also the tendency to close the case prematurely to rid oneself of the burden of attempting to solve complex problems. FURTHER DEVELOPMENT OF THE BIOPSYCHOSOCIAL MODELGeorge Engel formulated the biopsychosocial model as a dynamic, interactional, but dualistic view of human experience in whichthere is mutual influence of mind and body. We add to that model the need to balance a circular model of causality with theneed to make linear approximations (especially in planning treatments) and the need to change the clinician’s stance fromobjective detachment to reflective participation, thus infusing care with greater warmth and caring. The biopsychosocial modelwas not so much a paradigm shift—in the sense of a crisis of the scientific method in medicine or the elaboration of new scientificlaws—as it was an expanded (but nonetheless parsimonious) application of existing knowledge to the needs of each patient.In the 25 years that have elapsed since Engel first proposed the biopsychosocial model, two new intellectual trends have emergedthat could make it even more robust. First, we can move beyond the problematic issue of mind-body duality by recognizing thatknowledge is socially constructed.

Biopsychosocial Model Social Work

To some extent, such categories as “mind” or “body” are of our own creation.

The biopsychosocial modelThe biopsychosocial model introduced by George Engel in the late 1970s (see Engel, 1977) adopts the perspective that a full understanding of mental distress, as well as of mental health and well-being, involves a study of the biology of the body (usually with an emphasis upon the brain), an individual’s psychology and their social circumstances. According to this model, disease defined simply in terms of biology, is not a useful way of approaching distress and well-being.A central assumption behind the biopsychosocial model is that, not only do the three factors −biological, psychological and social − play a role in any form of psychological distress or well-being, but also that there is interdependence between them. For example, changing an individual's social circumstances can change his or her psychology.

Changing an individual's psychology can change their social interactions. Changing a person's psychological state will also change the activity of their brain. A change in the underlying brain activity, for example as a consequence of traumatic brain injury or a physical illness, can change the individual’s psychological state and their behaviour. In these terms, biology is not an absolute defining criterion of when there is mental distress, but neither is it irrelevant. A biological explanation can contribute to mental distress, but should be considered as one contributory factor amongst three.In health or ill-health, biological and psychological contributions will always be present.

In one sense, in the very rare cases of, for example, a person living alone on a desert island or a hermit in a cave, there will not be a social factor present. However, such a person will still have had a history of earlier social interactions which will have left their mark. So, according to a biopsychosocial model, the relevant question is not which factor, ‘bio’, ‘psycho’ or ‘social’, is the most important, since they are interdependent. At whichever level a change arises, there will be consequences for the other two. For example, a social change, such as finding a new job, a marriage, divorce or a bereavement (the loss of a loved one), will have obvious implications for a person's psychology, which simultaneously affects the brain. But a change does not necessarily occur in only one of the three factors at any one time.