A biopsychosocial model of health
Aspects of public health, psychosomatic medicine, and behavioural medicine as well as other related fields such as health psychology are brought together in the ‘biopsychosocial’ model, first articulated by American psychiatrist George Engel as a challenge to the biomedical model in a paper published in the journal Science in April 1977.(21) Engel proposed that the traditional biomedical model did not operate in isolation but was actually integrated with psychological factors and social factors with direct and indirect pathways to health.
As with psychosomatic medicine, the concept of the biopsychosocial model was not new. It can be traced back to the very origins of the Western medical tradition in the Hippocratic school of medicine, which placed an emphasis on environmental factors such as personal hygiene, sanitation, and nutrition. Furthermore, during the Middle Ages, when mortality rates were high with few cures available, there was a strong emphasis given to mental, social, and spiritual dimensions of health. It was only with the strides forwards made within medicine in the eighteenth and nineteenth centuries that the biopsychosocial model waned. In 2004, the prominent medical historian Theodore Brown was interviewed at the University of Rochester.(22) He explained that this move away from the biopsychosocial towards the biomedical in the nineteenth century was not surprising:
‘That’s actually a recurrent phenomenon that I see in medical history. When you have a new discovery, whether it be Pasteur in the 19th century or recent discoveries of penicillin, there’s such a desire for them and they play so well, they’re so sexy, and they’re so easy to market, both figuratively and literally, that they just overwhelm the rest of the field.’
Indeed, some have seen the biomedical model as a temporary impediment to a broader definition of health: it appeared to provide so many answers that at the turn of the twentieth century it was believed that all disease would be conquered in a short space of time. By reintroducing the biopsychosocial model, Engel aimed to revitalize the previous approach to health. The term itself—biopsychosocial—had actually been coined by the neurologist and psychiatrist Roy Grinker in 1954 as a way of emphasizing the ‘bio-’ within psychoanalytics. But Engel changed the meaning, instead emphasizing the ‘psychosocial’ within biomedical. Engel called the model a ‘blueprint for research, a framework for teaching, and a design for action in the real world of healthcare’. (21) In essence, Engel tried to bring the biopsychosocial back, not just as a theory or a concept, but as something practical.
Engel was not alone in his views, and in many ways encapsulated the thoughts of other scientists of the time.(23) However, worthy though the aims of those proponents of the biopsychosocial model were, there has been debate as to whether the biopsychosocial model was properly adopted. Indeed, the World Health Organization (WHO) definition of health, which encompasses a biopsychosocial approach, was, for a long time, considered an idealistic view of health, but not a practical definition. Psychologist Robert Ader, in the same interview with Theodore Brown in 2004 said he felt there was ‘more lip service to than actual implementation of the biopsychosocial model’ in clinical practice. However, Ader himself has arguably been credited with changing this through leading a new field of scientific research coined in the 1970s: psychoneuroimmunology. Brown explained:
‘In my view as a historian, psychoneuroimmunology came as a great shock because there, in the midst of the biomedical approach were unmistakably rigorous investigations and undeniably powerful evidence that seemed to question some of the foundations of the biomedical approach from a research point of view rather than a clinical one, and from hard data rather than from rhetorical pronouncements’
Psychoneuroimmunology demonstrated that the mind and immune system were connected bi-directionally, with psychological thoughts not only capable of altering immune activity, but the immune system itself also capable of feeding back and leading to alterations in psychological state. The importance of this research was that it provided further weight to the biopsychosocial model by showing that incorporating psychological and environmental factors into the clinical practice of medicine was not just an idealist position but was fundamental to understanding and treating diseases. Certainly, there remain debates such as around how comprehensively the biopsychosocial model is implemented in practice, but it is still generally recognized as the dominant theoretical model of health.
For more information on psychoneuroimmunology, Jorge H Daruna’s Introduction to Psychoneuroimmunology provides an accessible overview of different aspects of the field.(24)