In my last post, I briefly mentioned the biopsychosocial model and cited a criticism of it. However, having done a bit more digging, I’ve discovered that it seems to be woefully misunderstood in modern practice, both for physical and mental disorders.

Models of care adopted by medical professionals can often make it difficult for them to see the whole picture. Equally, professionals trained to offer psychosocial therapies are reluctant to consider biological causes of mental health conditions (and, regrettably, some physical conditions), mainly because they cannot offer solutions in those areas. The definition of disease has been largely driven by professional boundaries rather than reality.

When George L. Engel proposed the need for a new medical model, he did not intend it as an alternative to the biomedical model, but as a replacement for both biomedical and psychosocial models.

His intention for such a biopsychosocial model was that,

“To provide a basis for understanding the determinants of disease and arriving at rational treatment and patterns of health care, a medical model must also take into account the patient, the social context in which he lives, and the complementary system devised by society to deal with the disruptive effects of illness, that is, the physician role and the health care system.”

Engel was not intending that biomedical aspects of disease should be ignored or negated, or that psychosocial factors should be considered in isolation. He viewed both as equal partners, and crucial in the treatment of the whole person.

The problem with the (bio)psychosocial model as currently applied is that it tries to ignore the fact that diseases and disorders have biological causes and inputs. These may be genetic, developmental, infectious, structural or chemical, and this applies as much to the brain as it does to the rest of the body. The psychosocial model assumes that causes are mainly external and experiential and not internal and biological. It pits itself against the biomedical model as an alternative. However, it should not be alternative, it should be seen as complementary. I suspect that the reason it isn’t has more to do with professional boundaries and competencies than anything else. If your only tool is a hammer, then everything looks like a nail.

The vast majority of diseases and conditions are complex. There are very few for which we have found a single treatable cause: e.g. type 1 diabetes. And yet, here too, other factors play a huge part. Those with kids with diabetes will know only too well that psychosocial factors are crucial in the acceptance and treatment of the disease and that these should not be ignored.

The problem is compounded for conditions in which we don’t know the cause, that are “idiopathic”. The psychosocial model assumes that because we don’t know the cause, that there isn’t one, at least not a “real” or “organic” one. However, absence of evidence is not evidence of absence. It just means we haven’t quite got there yet. I don’t believe there are conditions that can be purely created by the subconscious mind without the conscious mind knowing about it (although I’m prepared to change my mind if such a thing could be definitively shown to be true, but I suspect it is frighteningly rare). It makes much more sense for there to be an organic cause. We are biological beings. When we feel that something has gone wrong, it is usually because something has gone wrong, and not because our brain unknowingly willed it to be so for some covert ulterior motive.

What is most disturbing is that the very people who could be an enormous help in many conditions – helping patients come to terms with their chronic disease and finding ways to improve their quality of life – have gone down a path that hampers that and in doing so have lost their patients’ trust. That this has occurred on both sides of divide is more concerning. There are psychologists who are so embedded in the biomedical camp that they refuse to use psychological methods on those who might derive benefit from them to help come to terms with their disease. And there are clinicians so wedded to psychosocial dogma that they will insist that the search for biomedical attributions perpetuates the condition.

Disease is biomedical. Some of the mitigating factors or consequences may be psychosocial (or cultural or spiritual). Some of the solutions may be psychosocial or medicative, and many strategies may be needed. But ultimately, it is what works for the patient that is important, not what works for the clinician.

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Update (10 April 2016): George Berger has pointed me towards his blog on this subject – Gordon Waddell’s biopsychosocial attack on disabled people