A Critical Review of the Biopsychosocial Model, 1998, McLaren

Paywalled https://journals.sagepub.com/doi/abs/10.3109/00048679809062712
Sci Hub, https://sci-hub.se/10.3109/00048679809062712

 

This is an old paper, but it got me thinking...

There are certain "positions" that are sometimes put forward by those working in health, psychiatry and related fields that seem to be really saying something, but when you reflect on them, they aren't really saying anything at all.

The biopsychosocial model - the idea that we should consider biological, psychological and social factors when explaining disease - sounds so sensible, doesn't it? But then when you think about it, nobody seriously holds the opposing position, do they? Nobody really goes around thinking that everything there is to know about diabetes can be learned by studying insulin reactivity and other physiological changes, and we should ignore everything else, do they? Of course the person's emotional response and social situation matters, and may have consequences for managing the disease. Nobody really thinks "oh, let's just study the one level, there's no need to look at anything else". Everyone realises that's just stupid.

So the opposing view to the biopsychosocial model is nothing more than a straw man.

Also, people who advocate ideas like BPS (and other similar ones, like "integrative pluralism") often caricature other people's approaches in order to make theirs look better. If a person decides to look at functional brain abnormalities in schizophrenia, they are accused of being "reductionistic", of blindly excluding the possibility that higher level factors might be relevant. Its a slur, no-one wants to be seen as doing that. But nobody really is, are they? Those researchers looking at neural factors in schizophrenia, are any of them really thinking that there's nothing to be added by studying the psychological level? More likely, they just think that the neural level might have a lot to tell us.

On the other hand, if you take the BPS idea at its word - that we should give all levels of description equal weight in our explanations of health problems - that's also stupid. Different levels of description will do different amounts of explanatory work depending upon the problem. So for something like Huntingdon's chorea, a genetic neurological disorder, there's not much causal stuff happening at the social or even the psychological level. The person can change their social situation, modify their thoughts and feelings, and none of it will make a sod of a difference to whether they end up with full-blown Huntingdon's chorea. Conversely, if you grew up in the favellas of Rio and ended up running errands for some drug lord - and got caught and sent to prison - no amount of medication or neurosurgery will "reform" you, because there's nothing wrong with your body or brain. Social factors are going to be doing most of the explanatory work here.

 

@Woolie brilliant.

ME/CFS patients also do not reject the importance of mental health, we just have very different ideas about what it means, and we do reject the specific model put forward by CBT/GET proponents.

Patients continously point out how harmful and distressing it is to be sick and not be believed. What is this, if not patients talking psychosocial factors?

I also think that CBT/GET are harmful to mental health, because they create unrealistic hope and expectations that cannot be met. They also come from a place of misunderstanding the condition and therefore perpetuate misunderstanding.

 

This I am fairly sure is wrong. The model was always about psychogenic disease, from the outset. Read the original papers by Engels, and look at his position on these issues from other sources. What has happened, in my view, is its promoted as a broad approach to medicine, but a large number of those in the BPS framework are psychogenic proponents.

BPS superficially makes a lot of sense, but it does not give you solid ground on where to advance this in any rational or evidence based way.

I wrote several blogs on these issues on Phoenix Rising. I quoted McLaren once.

 

So true, @Woolie, @strategist and @Trish.

The first time that I heard re the BPS idea, I felt exactly the same, ie all illnesses are influenced by biological, psychological and social factors to varying degrees.

Last time I was having steroid injections in my sacro-iliac joints by the pain management clinic I raised this with the Consultant.
(He has three psychiatrists in his family, wife, son and daughter-in-law and refers to himself and young granddaughter as, the "only sane ones" in the family. His relatives do not work in the ME field)

He seemed happy to agree with my first two examples, but when I mentioned cancer he couldn't get his head round it at all. Although obviously the thoughts/fears on having that diagnosis and facing the treatment as well as the finance and family/friend support will again have a huge impact on outcomes and the whole process.

I didn't ask him whether he had watched Unrest yet, which I'd given him previously.

Unfortunately he does not seem to grasp the fact that there is altered physiology/biochemistry in ME/Fibromyalgia. Given the NHS and media narrative, this is hardly his fault. I went with a friend to her Pain Clinic appointment.

His main focus is Central Sensitisation.

However he is prepared to consider the full range of meds etc and accepts that she has significant pain.

 

I thought the heart attack example was Engels's original paradigm. My reading of the development thereafter is very much as suggested by Woolie and Trish. And of course the Aylward biopsychosocial interpretation (being ill is a decision) gets mixed in around 2000.

 

My reading of Engel is less positive. He is very vague. The purpose of this article seems to have been exactly that of protecting dysfunctional psychogenic illness models. That doesn't mean that he didn't say a few sensible things, but that he said them so that the non sensible practices could continue.

The context in which the article was written was also basically the demise of Freudian psychoanalysis, which had argued things such as cancer stemming from emotional problems.

 

Fair enough.

 

Some of mine blogpost at this particular subject:

Blogpost 2mai2015: The Myth and the Scientific Fraud of the bio-psycho-social model |https://totoneimbehl.wordpress.com/...entific-fraud-of-the-bio-psycho-social-model/ via Marit @memhj at ToTo NeuroImmunologisk Kurativ Behandling
(most text in eng.)

Blogpost 3mai2015: På ME-fronten: Det er mye sannhet i........ | https://totoneimbehl.wordpress.com/2015/05/03/pa-me-fronten-det-er-mye-sannhet-i/ via Marit @memhj at ToTo NeuroImmunologiks Kurativ behandling
(partly eng. use the translater at the netsite)

Blopost 8may2015: På ME-fronten: Battle Damage Assesment https://totoneimbehl.wordpress.com/2015/05/08/pa-me-fronten-battle-damage-assesment/ via Marit @memhj at ToTo NeuroImmunologiks Kurativ behandling
tags: Prof. Malcom Hoopers rapport/dokument «Magical Medicine: How to make a disease disappear», PACEtrial mm (part eng. use google translate)

Regards marit

 

It was an attempt to give some sort of theoretical basis to what the Freudian psychotherapists and psychiatrists had been doing.

Fast forward until today and we have the CBT/GET theorists that are caught in a situation where it is apparent that there is no scientific basis to what they've been doing. Some, like Fink, are once again trying to reinvent some new approach and secure some space for themselves (although it's mostly a rebranding). If you read some of his papers, he often says all the right things, but in the end what he does is still trying to cure illness with psychotherapy.

 

What's also popular now is claiming that psychotherapy can reverse neuroinflammation, or allow patients to change harmful physiological processes at will (that is what Phil Parker claims). It's just more rebranding. Nobody has actually done the scientific work that would demonstrate this.

 

Even if it is true that many physicians overlook psychosocial factors, I doubt that's because they consider these factors unimportant. More likely explanations are that doctors think they have little influence over these psychosocial factors (they can't undo a divorce, a death or a stressful environment) or that they do not think they have the time/monetary incentive to go into these.

So instead of thinking psychosocial factors are unimportant in determining health and illness - which, as Wooly explained, probably nobody thinks - these doctors might think that there are few cost-effective interventions to help improve psychosocial factors.

It's nice to claim that all three elements - the biological, the psychological and social - are important in determining health, but what really matters in clinical practice is what you can do about it. If all three are equally important but only one offers an effective treatment, that would justify a focus on that one. I think the history of medicine has shown that the biological element, offers the most promise to effective treatments.

So instead of providing a holistic view on illness and disease, I see the BPS model as more about making optimistic claims about psychosocial interventions. Everyone agrees psychosocial factors are important, the disagreement seems to be how effective and important psychosocial therapy is.

 

This was the position some critics took. Engels was very much pro-psychogenic, and was writing about it long before the classic BPS paper.

 

This.

 

There are three points I would like to make. This also applies to extreme positive thinking. The other issue is that these claims create expectations within government that there are easy answers to be had with these approaches. Yet they tend not to objectively evaluate long term outcomes. They just presume the "experts" have it right, for the most part.

There is no shortcut to good science. Shortcuts tend to be pseudoscience, particularly since many of the worlds major scientific issues that are left are deep and complex. Its the same with medicine. The deep and complex requires sustained good science.