Thursday 29 August 2019

The Biopsychosocial Model of Health and Disease

Today's post is by Derek Bolton. He is Professor of Philosophy and Psychopathology at King’s College London. His latest book co-authored with Grant Gillett is The Biopsychosocial Model of Health and Disease: Philosophical and Scientific Developments (Springer Palgrave, 2019, Open Access).

Imagine how odd this would be: You or the family were attending clinic (say neurology, orthopedic, pediatric or psychiatric), enquired about causes and cures, and the reply referred to complexity and the Biopsychosocial Model. You go home and look this up, and happen upon criticism by many authoritative commentators to the effect that the Biopsychosocial Model, popular though it is, is scientifically, clinically, and philosophically useless. This is actually where we are and this is the problem we diagnose and address in our book.

We propose a formulation of the problem along the following lines: The 1960s and ‘70s saw the beginnings of systems theory approaches in biology, in principle extendable to psychological and social phenomena. George Engel was among those who saw quickly the relevance to health and disease. Especially that the exclusively biological focus of biomedicine could and should be expanded to include psychosocial factors in a new biopsychosocial medicine/healthcare. Since that time, evidence has accumulated from a wide range of epidemiological and clinical studies suggesting the involvement of psychosocial factors in the aetiology and course of a wide range of physical and mental health conditions. While the Biopsychosocial Model has stood ready to accommodate these findings, its ability to theorise them has not been updated since the programmatic formulations of systems theory. Especially problematic are deep scientific, philosophical assumptions about the impossibility of psychosocial causation in long traditions of dualism, physicalism and reductionism.

The remedy we propose is along these lines, starting with biology:

We note that biology and biomedicine since the middle of the twentieth century has become as exquisite combination of two kinds of science. One is the physics and chemistry of energy exchanges – following fixed laws, covered by the inviolable equations – as for inanimate matter. But added to this there is a new science of systemic information-based regulatory mechanisms, the operation of which are typically system specific and which can, in stark contrast to physico-chemical energetic equations, break down. In short we now find already in biology more than physics and chemistry: ontology and causal principles based in systems theoretic concepts of system, form, function, information/communication, organisation, regulation and error. We note then the critical point that these same concepts and principles run through psychology and social sciences, creating the possibility of cross-talk across these previous problematic and unconnected domains.

We suggest that the core psychological function – which all others serve – is agency. Agency here is short for embodied agency, linking with the phenomenological philosophy and the new cognitive-affective neuroscience of embodied mind. Biomedicine has confined itself to, roughly, what is below the neck, while the rest is mental. In the new philosophy and science, biomedicine talks with neuroscience/psychology.

We blur the psychological and the social using the concept of recognition, again with broad scope, from inter-personal recognition of each other’s agency and associated mental states, through to socio-political recognition. We adopt a familiar view that social structures and processes function to produce, organise and regulate the distribution of resources. This refers to resources necessary for our biological nature, but also resources necessary for our psychological nature, namely, cultivation and exercise of agency, education and opportunities, which depend in turn on inter-personal and socio-political recognition. The theory is related to what is now known about biopsychosocial factors affecting health and disease, the social gradient of health and health inequalities, chronic stress, anxiety and depression, and biopsychosocial factors in the management of long-term conditions.

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