Biopsychosocial model 25 years later

George Angel's legacy

The late George Engel believed that the clinician must take into account the biological, psychological and social aspects of the disease - only then will he be able to correctly understand the cause of the patient's suffering, offer adequate treatment and win the patient's trust. Dr. Angel put forward a holistic model as an alternative to the conventional biomedical approach that has reigned supreme in industrial societies since the mid-20th century [1] . The model he created is known as the biopsychosocial model. It took shape during the period when interdisciplinary, contextual, systemic approaches began to replace exclusively analytical, reductionist and specialized methods in science [2] . Angel did not deny that impressive advances had been made in the mainstream of biomedical research. He only criticized the excessive narrowness of the biomedical views of leading clinicians, who saw the patient only as an object and did not attach importance to his subjective experiences, which could become the subject of scientific research. Angel promoted his ideas not only as a scientific hypothesis, but also as a fundamental ideology with which he tried to counteract the dehumanization of medicine and the lack of rights of the patient. His ideas touched sensitive chords in the souls of those doctors who sought to make compassion and empathy part of medical practice.

Biomedicine: Angel's Critical Arguments

1. Biochemical deviations from the normal state of the body are not a disease. The disease is the result of the interaction of diverse factors, including at the molecular, individual and social levels. The opposite is also true: psychological changes under certain circumstances can manifest themselves in the form of somatic diseases or suffering that pose a threat to health. Sometimes they may be accompanied by corresponding biochemical changes.

2. Violation of a biological function in itself is not sufficiently informative. For the patient, it does not explain the meaning of the symptoms, and for the physician it does not contain information about what skills and knowledge he must have in order to successfully collect and process clinical data.

3. The psychosocial component influences the predisposition to the disease, its severity and course much more strongly than was previously imagined by supporters of biomedical views on the disease.

4. Taking on the sick role is not always due to biological dysfunction.

5. The success of many biological treatments may be influenced by psychological factors (eg, the placebo effect).

6. The relationship between the patient and the doctor influences the outcome of treatment, if only because it determines how consistently the patient adheres to the chosen method of treatment.

7. The patient (as opposed to inanimate objects of study) is extremely influenced by the method of research itself. The researcher, in turn, is also influenced by the observed patient.

In this article we make an attempt to critically, taking into account new data, analyze the experience of applying the biopsychosocial model in the three areas for which it was proposed as a “new medical paradigm” [3] , namely:

1) as a medical ideology, covering not only objective biomedical indicators, but also the subjective experience of the patient;

2) as a model of cause-and-effect relationships, which seems more complete and natural than an elementary linear reductionist model;

3) as a model of the relationship between the patient and the doctor, which gives the patient more rights to participate in the treatment process, turning him from a passive object of research into an active participant and protagonist of the treatment process.

We will also explore connections between the biopsychosocial model and evidence-based medicine.

Dualism, reductionism and the position of a detached observer

In promoting his biopsychosocial model, Angel proposed alternatives to three fundamental medical concepts that, in his opinion, led to the dehumanization of medical care. First, he criticized the dualism of the biomedical model with its separation of body and mind (an approach that is often, although perhaps incorrectly, traced back to Descartes) [4] . Within this concept, the body is by default considered more “real” and therefore more worthy of the attention of the clinician-researcher. As a result, the disease and the person are perceived in isolation, the doctor’s attention is focused on the disease, and the person and his suffering are excluded from view. Angel rejected the dualistic approach that encouraged doctors to draw a clear line between the patient's perceived body as a "machine" and what the patient tells about himself and his experiences. Angel's research in the field of psychosomatics has shown that fear, rage, neglect or attachment can have direct physiological effects on the body and its development, guiding doctors towards a different, integrative approach.

Secondly, Angel's criticism was directed against the predominantly materialistic and reductionist style of medical thinking, in which everything that could not be objectively confirmed and explained at the level of cellular or molecular processes was ignored or discarded. The cold, impersonal, technical, biomedical-oriented style of clinical practice was what Angel protested. The point here, apparently, is not so much a disagreement over philosophical foundations as the impossibility of reconciling with medical practice that neglects human suffering. In a 1980 article on the clinical application of the biopsychosocial model [5] , Angel reviewed the case of a man with chest pain whose lack of attention from his physician caused an arrhythmia.

The third factor is the influence that the observer has on the observed. Angel realized that it was impossible to examine a system from the inside without influencing it in some way. In other words, in the “human dimension”, as in the world of quantum physics, a position of absolute objectivity is impossible. Based on this, Angel argued that the “human dimension” of medical practice, that is, the positions of the doctor and the patient, should become full-fledged objects of scientific research.

Angel's views contrasted sharply with so-called monistic or reductionist views, according to which all phenomena can be reduced to the level of small particles and understood as molecular interactions. He was also not a supporter of holistic-energetic views, many of whose supporters are not alien to the biopsychosocial approach (according to their views, all physical phenomena are transitory, they can be controlled through the manipulation of healing energies). Thanks to systems theory [6] , Angel came to understand that although mental and social phenomena depend on underlying physical phenomena (as far as the current level of scientific knowledge allows us to judge the latter), they cannot be reduced to them and explained using appropriate terminology. The approach he put forward would now be called systemic [7] . Angel believed that different levels of the biopsychosocial hierarchy can interact, but the patterns of their interaction cannot be derived directly from the principles inherent in the upper or lower rungs of the biopsychosocial ladder. The result should rather be considered unpredictable, depending to a very large extent on the personal characteristics of the patient and on the initial symptoms. A comparison with the weather, which is influenced by both initial conditions and small disturbances, is appropriate here. [8] . For several decades, this approach has inspired researchers seeking to clarify the nature of such interactions.

Systems approach: circular and structural models of causality

Angel did not accept the use of a linear cause-and-effect model to describe clinical phenomena. Clinical reality is much more complex. For example, although heredity plays a role in the occurrence of schizophrenia, not a single clinician would deny that social factors can provoke or restrain the manifestation of this disease.

Systematicity and causality

Only a small part of pathologies can be described by the formula “one type of bacteria - one disease”; in reality we are dealing with many interacting causes and factors. Thus, obesity leads to both diabetes and arthritis; obesity and arthritis reduce a person's mobility, which negatively affects blood pressure and cholesterol levels; and all of the above factors, with the exception of arthritis, contribute to both the occurrence of stroke and the development of coronary heart disease. Some of their consequences (depression after a heart attack or stroke) can themselves cause a second attack, increasing its likelihood. Similar conclusions can be drawn by observing predictors of relapse in schizophrenia. These observations provide the basis for constructing a model of circular causation, which shows how a series of cycles of interactions influence specific behavioral patterns over time [9] .

Using systems analysis, one can try to understand the entire complex of recursive and emergent (i.e., unpredictable) properties of systems [10] . The clinician's task is to find exactly the group of interdependent factors whose effects can be changed by resorting to the right combination of intervention methods (in the case of schizophrenia, psychological support for the family and drug treatment of the patient; after a heart attack, prevention of depression and lowering cholesterol levels).

Structural model of causality

8 Unlike the circular model, the structural model describes a hierarchy of unidirectional cause-and-effect relationships: necessary, trigger, supporting and accompanying factors [11] . For example, for the development of tuberculosis, a necessary factor is mycobacteria, the trigger that starts the process is a decrease in body temperature, and the supporting factor is insufficient caloric intake. Systems analysis can clarify the clinical picture, but practical decisions are usually made on the basis of a structural model. For example, when we assume that Mr. J's hypertension is caused by excessive salt intake, a stressful job, insufficient social support, and the fact that he is one of what is called "over-responsible people," we are using a circular model of causation. Perhaps all these factors caused the increase in blood pressure. However, by prescribing antihypertensive drugs for Mr. J., recommending that he consume less salt, take a course of anti-stress therapy, or consult a psychotherapist to reduce obsessive feelings of guilt, we are quietly building a hierarchy of causes. Which one is most responsible for the increase in blood pressure? Influencing which factor will lead to the greatest success? What will be the additional effect of one of the activities after completing the others? Which strategy will bring the greatest result with the least harm and the least cost?

Interpretations, language and cause-and-effect relationships

Arbitrarily establishing the cause of a disease can generate a new reality, changing the patient’s worldview [12] . An attentive doctor may agree with the patient’s fears that a family conflict contributed to the occurrence of myocardial infarction; but this explanation, although important for the patient, does not exhaust all the causes of the disease. By arbitrarily naming one of the factors as a cause, you can hold the patient responsible for his illness (“If only you hadn’t smoked so much...”). Attributing a reason has the power of suggestion and can worsen the patient’s condition (“Every time after a quarrel you feel more dizzy, don’t you notice?”).

Towards a partnership model

The relationship between doctor and patient: powers and experiences

The patient-centered partnership approach places the primary focus on the physician-patient relationship [13] . In this approach, establishing the correct biomedical diagnosis is only part of the task assigned to the physician. It is necessary that illness and health be interpreted from the patient’s point of view, so that he has the opportunity to express what worries him and what he expects from doctors. It is necessary for the patient to see the person’s face facing him, and not just the face of a specialist. The partnership approach embodies a movement towards an equal relationship between doctor and patient, one in which the doctor consciously and carefully exercises his rights.

This “dialogical” model assumes that the reality that exists in the patient’s mind is not simply interpreted by the doctor, but is jointly created and adjusted in the process of their communication [14] . The patient's self-identity is embedded in their dialogue and reinforced during social interaction [15] . The doctor’s task is to listen to the patient and share with him his understanding of the disease. This does not mean that we must uncritically accept all the patient’s opinions and hypotheses, but we should not blindly reject the patient’s point of view, as often happens, for example, when he complains of symptoms that the doctor is unable to explain [ 16] . The patient’s story is information about his life, and the present moment of his life, his momentary living, and a set of data on the basis of which it is necessary to formulate a diagnosis and develop a treatment plan.

The doctor's power rests on his ability to cope with the flow of strong emotions that permeate everyday clinical practice. There is a reactive style of behavior in which the physician immediately responds to expressions of hostility or mistrust with denial or suppression. On the contrary, the openness and attention to the patient's experience inherent in the proactive style of behavior of the clinician allows one to calmly respond to the patient's negative emotions and use them to strengthen the partnership between the patient and the doctor [17] .

To learn tolerance and understanding, the clinician must recognize and overcome his tendency to divide patients into agreeable and difficult ones. We must get rid of these stereotypes; they must be replaced by sincere sympathy, growing from a consciousness of solidarity with the patient and respect for his human dignity [18] .

Thus, the requirement to treat the patient as an individual entails the need to engage in in-depth self-knowledge [19] . Without understanding himself, a doctor can easily confuse empathy with projecting his problems onto the patient.

Relative autonomy

Most patients would like to receive more information from their doctors, a minority would like to be directly involved in clinical decisions, and few are willing to make important decisions without consulting a doctor or discussing the problem with their family [20] . This does not mean that patients, even the seriously ill and elderly, want to remain passive [21] . But there are cases when the doctor unintentionally shifts all responsibility onto the patient [22] , against the will of the latter, placing on him too heavy a burden of knowledge about the disease and the need to make decisions himself. The patient lacks competent medical opinions; without medical advice and family support, he feels abandoned [23] . The ideal may be “relative autonomy”, in which the patient, feeling supported and cared for, makes informed choices [24] . Well, since there is a possibility that the patient does not want to know the whole truth about his illness, and would like to entrust decision-making to his family members, the doctor can invite him to choose the degree of autonomy himself [25] .

Social environment

All contacts between people have an ecological dimension. We are talking not only about the relationship between the patient and the doctor, but also about social norms in general [26] . Sometimes a doctor finds himself in a dilemma: can, should a private relationship between a patient and a doctor be transformed into an instrument for transforming the patient’s social life? Or should a doctor building a relationship with a patient respect the latter’s cultural norms and adapt to them himself? [27] In our opinion, it is necessary that any attempts to make changes in the patient’s life be preceded by a period of studying his cultural norms and accommodation. Otherwise, the relationship between the doctor and the patient turns into a cold war, and then the patient’s dissatisfaction and his disagreements with the doctor themselves become the main problem of the treatment process. What if the patient suffered, for example, from domestic violence or became a victim of torture? The matter becomes even more complicated [28] : a doctor who does not try to change the social situation that has traumatized the patient may not be able to establish a trusting relationship with him. But along this path, the doctor is faced with the temptation to reshape the patient’s life - for example, to advise a woman who came to an appointment only to get help for bruises from beatings at home to leave her family. Hasty advice can prevent the patient himself from realizing the need for change and taking the initiative into his own hands. Refusal to interfere in the life of a patient who did not consent to it cannot be interpreted as indifference, approval or complicity, but rather prudence, which will ultimately pay off.

Medical care, paternalism and empathy

According to Angel, the problem is not created by paternalism, but by the doctor’s working style, which turns him not into a caring healer, but into a soulless technologist [29] . A doctor who considers himself merely a technical consultant thinks that empathy is a waste of energy that has no impact on medical decisions, or, worse, that it is a set of verbal tricks needed only to get the patient to agree to the proposed treatment. But since we can justify the benefits of joint decision-making between the doctor and the patient, without even challenging the point of view of adherents of “soulless technology,” we propose to move on to considering an approach that puts human warmth, attention, generosity and care at the forefront.

Biopsychosocial model and humanity

We call the practical application of the biopsychosocial model biopsychosocially oriented clinical practice. The latter is not necessarily the fruit of such theoretical constructs as the dualism of thinking and brain or circular causation. Rather, it is based on trust and other emotions that permeate the patient-doctor relationship. Trust is a fundamental principle of biopsychosocially oriented clinical practice, in which the professional activity of a doctor is spiritualized. With rare exceptions [30] , in most medical publications, when describing the relationship model, the authors focus on the professional powers of the doctor and rarely pay attention to what determines the emotional climate of the relationship between the doctor and the patient. Therefore, in our formulation of the basic principles of the biopsychosocial model, we attach special importance to the emotional background that creates an atmosphere of care, trust and openness in the relationship between doctor and patient [31] . Some principles of biopsychosocially oriented clinical practice are outlined below.

Doctor training

The biopsychosocial model provides for an increase in the variety of skills that a physician must master through focused training. The presence of these skills necessary to maintain a patient-centered style of health care can be objectively monitored [32] . A doctor can be compared to a musical instrument: in order for the sound to be flawless, it must be perfectly tuned [33] . A doctor's skill is judged by whether he is able to restore a patient's health or alleviate his suffering - whether through his ability to create the right emotional atmosphere, correctly collect anamnesis, or distinguish between the patient's true needs and his expressed wishes. By virtue of his profession, the doctor has the moral right not only to find out what worries the patient, but also to make demands on him, influencing his behavior. Sometimes this requires identifying the psychosocial correlates of otherwise unexplained somatic symptoms (they can be caused, for example, by chronic violence or alcoholism) and thereby breaking the vicious circle of drug addiction or iatrogenic diseases [34] . To refuse these obligations means, it seems to us, to violate the unspoken social contract between doctors and society. A purely consultative approach, in which the main role is given to the doctor and not the patient, is fraught with danger. A doctor must be able to constantly monitor his actions - simply because the effectiveness of his work is never constant. Wake and Sutcliffe [35] argue that in those areas of activity where unexpected situations constantly arise, the professional is required, above all, to be vigilant and self-controlled. To keep a cool head at all times, remain cheerful and open to compassion, the doctor must have keen observation and curiosity, a critical and flexible mind, competence, and always be focused and collected [36] .

Trust the patient

An experienced clinician believes that the ability to take the right tone and establish a relationship with a patient that would help treatment is one of the main professional skills. Each medical consultation can be assessed by how cordial and natural the doctor was, whether he was able to instill optimism in the patient and convey to him a good mood. Respectfully accepting an unfriendly patient [37] , the doctor distances himself from his negative emotions and builds a conversation so that the patient, in turn, treats his words with respect. Of course, the doctor must be able to analyze and manage his own emotions, be able to express them, and, if appropriate, restrain them in order to maintain a fruitful dialogue with the patient.

There are no “uninteresting” diseases

The ability to take a “naive”, unbiased look at clinical data [38] can be considered one of the main skills that characterizes an experienced professional. Therefore, in the next step, when using clinical data to provide medical care, the doctor needs to cultivate curiosity. A feature of this emotional attitude is empathetic attention to the patient as an individual. It allows the clinician to avoid being closed-minded: after all, no medical history can be considered completely closed. If the patient did not surprise us today, maybe he will surprise us tomorrow? We have described in detail [39] this ability to be surprised every day, the ability to expect the unexpected, calling it the “beginner's gaze”: the doctor should examine a familiar patient as if for the first time. This attitude includes an ethical component - for a doctor there can be no “good” or “bad” patients, no “interesting” or “boring” diseases. Patients are not required to confirm the truth of their suffering by talking about symptoms that are convenient for the doctor, that help him feel confident [40] .

Reflection and bias

In medicine, the rationale for decisions is based on both scientific evidence and the professional experience of the clinician. Now this principle, introduced by the founders of evidence-based medicine [41] , has become generally accepted. However, methods for integrating professional experience are much less developed than the system for assessing scientific evidence. In particular, clinicians should recognize the extent to which their decisions may be influenced by a patient's race and gender [42] . It is also important to be aware of the tendency to close medical records prematurely to avoid the need to puzzle over complex cases [43] .

Emotional stability

Methods of emotional education are in many ways similar to the usual methods of teaching new knowledge and skills [44] . For example, the ability to tolerate a state of uncertainty can be assessed. The physician needs to develop this ability because the practitioner needs the ability to make decisions in the face of limited information, as opposed to a technician who sees his role as strictly following protocols.

Knowledge and intuition

The role of intuition is difficult to overestimate. As Polanyi and Schön showed, professional competence is based more on implicit than explicit knowledge [45] . Competence often manifests itself in intuitions that are difficult to justify at a strictly cognitive level. If a clinician, faced with a state of affairs in which he usually prescribes a certain treatment, suddenly, for some reason unclear to himself, intuitively feels that it is not quite suitable for a given patient, we believe that he should not discard this feeling. You should not think that it came from somewhere unknown. It will probably become clear later that the doctor's intuition was based on a number of specific observations about the patient, which at that moment were difficult for the doctor to formulate. And although all this most often becomes obvious only when the medical history is analyzed post factum, the moral duty of the doctor is to use all his abilities for the benefit of the patient, and not just those that are easy to explain.

Patient information

Clinical information should be communicated to the patient in a form that he can understand and in small portions so that he can assimilate it. Information overload leads to a double negative effect: misunderstanding and increasing the emotional distance between the doctor and the patient. The purpose of informing the patient is to achieve mutual understanding with him, and not just to answer questions [46] .

Further development of the biopsychosocial model

George Engel's biopsychosocial model reflects a dynamic, interactive, yet dualistic view of human experience in which mind and body interact. We have expanded this model by balancing circular causality with a linear approximation (especially important in the treatment planning stage), and added the following requirement: the clinician's position should not be the detachment of an objective observer, but a thoughtful collaboration with the patient, which will bring human warmth and care to medical care. The introduction of the biopsychosocial model is not so much a paradigm shift caused by the crisis of a certain scientific method or the discovery of a new law, but rather a careful expansion of the range of tools, a more complete use of the knowledge accumulated by science in the interests of each patient.

In the 25 years since Angel put forward the biopsychosocial model, two new approaches have emerged in science that can support this model.

First, the problem of mind-body dualism can be overcome by accepting that knowledge is a social construct. Categories such as “mind” and “body” are to some extent the fruit of our creativity. They are useful as long as they serve as cognitive and practical guides (for example, helping to better use resources to improve quality of life and health). However, if taken too literally, they cause confusion and create barriers to thought that do not exist in reality. We use these, in the words of William James [47] , “soft” categories, but we are free to change their content or discard them as we accumulate new knowledge and when the need for a fresh look and an unbiased approach arises.

Secondly, we can go beyond the framework of multidimensional and multifactorial linear thinking, taking as a basis a systems approach that is more adequate to the task of understanding causality, dualism and partnership in medicine. According to systems theory, in open systems it is often impossible to take into account all the factors that affect health in each specific case. By describing the usual ways in which systems self-organize, this theory provides the clinician with general guidelines on which he can rely in his actions, and also relieves him of unrealistic expectations, proving that it is impossible to control all factors and influences [48] .

Central to George Angel's legacy is the expansion of the horizons of clinical thinking. The promotion of the biopsychosocial model was a requirement to change our attitude towards the patient, to expand the field of medical knowledge in accordance with the needs of each patient. Changing the way we think about disease, suffering, and treatment may have been Angel's most lasting contribution to science.

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*Fr. Borrell-Garrio, AL Suchman, RM Epstein. The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry. In: Annals of Family Medicine. Vol. 2, No. 6, November/December. 2004. Translation from English by Dmitry Epstein.

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