A little history
When we talk about the biopsychosocial model of patient care, we quickly talk about Georges Libman Engel (1913-1999), a general practitioner and psychiatrist. But if we take a step back, almost 200 years in fact, the Abbé Bonnot de Condillac already brought out the beginnings of what would be called "systemic thinking" in his book The Theory of Systems. This mode of reflection and definition of reality then grew essentially during the XXth century to end up being explained in 1968, although the bases and roots of systemics are multiple, by Ludwig Von Bertalanffy (1901 - 1972), biologist, in his book General System Theory. The emergence of this theory is for many scientists a new breath of fresh air to approach complex problems, to make new advances emerge, but it has also been visibly a source of confusion and has been the subject of a lot of definition and conceptualization [1].
This is how we could summarize systems thinking: A system (a phenomenon, an event, an organization etc...) is a disorganized and non-hierarchical sum of sub-systems, and dependent on the other systems that surround it. Thus, everything that occurs by, for, against this system, is explained by the existence and the global interaction of the subsystems that compose it, and of the other systems that surround it. The understanding of what happens cannot therefore be reduced to a purely rationalist logic (that we know, that we know) of simple and reproducible causality, then considered as "reductionist-mechanist".
While the need for multidisciplinarity became a preponderant idea of systems thinking, this paradigm was mostly used to approach very special sectors (cybernetics, information theory...), but Ervin Laszlo, a Hungarian philosopher of science, transcribed this model of thought to the Human being in 1972 and made us glimpse the possibilities for medicine[2] [3].
It is from there that G. L. Engel will think and develop this famous Biopsychosocial model[4].
A new look
Like other of his contemporaries, he tries to have a critical look at a rationalist, Cartesianist, reductionist model that dominates the etiological reasoning of the time, known as Biomedical: all pathologies, complaints of the patient, suppose a biological or mechanical origin. He tries to expose its limits and to think of a model that will help even more people: "The traditional biomedical point of view, according to which biological indices are the ultimate criterion defining the disease, leads to the current paradox, namely that some people whose laboratory results are positive are told that they need treatment when in fact they feel quite well, while others who feel ill are assured that they are well, i.e., that they do not have a 'disease. A biopsychosocial model that includes the patient as well as the illness would encompass both circumstances" (Engel, G. (1977). The need for a new medical model: a challenge for biomedicine). Engel points out that the model is good, that it manages to explain many events, that it allows to treat many people, but that it can be improved. The meshes of the fisherman's net are narrow enough to catch some fish, but too wide to keep others.
The biopsychosocial model then transforms the patient-object, a simple machine governed by stereotyped biological, physiological and mechanical balances, whose deficiencies would generate pathology, into a patient-actor, a complex being formed by all of his beliefs, experiences, knowledge, ambitions, objectives, fears, fears, limits, embodied in a social context, an environment, a world of which he constantly receives and processes information. And it is all these "subsystems" that will be involved to a greater or lesser extent in a modification of his health.
Thus, does the famous patient whose biology results are "bad" while he reports feeling perfectly well, deserve the label of "sick" that the biomedical model was tempted to stick on him? And the other person, who says he does not feel well, but whose condition he describes is not explained by any biological or mechanical marker, can he finally be considered as being in real pain? It is currently noted that 25% of hospital consultations concern "sick" people without underlying pathologies[5]. How can we explain this suffering with a model of medicine focused solely on the biological?
Not so recent and yet still poorly integrated
Although this model is recognized as effective and allowing for a change in the way chronic diseases are managed, in particular by stopping the dispossession of individuals from their health and creating strong and effective therapeutic alliances, also highlighting an advantageous socio-economic interest, it is noted that this model is still poorly understood or little known by clinicians, but also poorly used by research actors in studies with poor quality designs, where the term biopsychosocial is used wrongly[6]. While Engel and his contemporaries criticized a model centered on physiological markers, we are now noticing the opposite excesses where everything is directed towards the psychological, the social, or still and always on the biological but hidden behind more modern terms. For example, we try to change the behavior of the subjects, to teach them knowledge that we think we have acquired, to explain the functioning of pain in the light of our knowledge of neuroscience. We prescribe them exercises because we know that this is the most reliable in the medium/long term or we tell them that they are not strong enough. We mobilize them, manipulate them. Once again, we can tend to deprive the individual of his reality in order to format him to our reality as clinicians: what is the point of explaining to him how pain works if he has not formulated that it would interest him and perhaps help him to get better? What is the point of absolutely wanting to reorient behaviors if the idea that this could be involved has not been verbalized beforehand? What is the point of manipulating an individual who feels deeply weakened by his condition? What is the point of ordering a patient to do exercises when we don't know if they are going to be done, or if it is to make them believe that they are fragile? What is the point of trying to strictly correct them in their beliefs when they are meeting us for the first time and do not know us? What are the strengths of our own beliefs? Are we clinicians able to evaluate our own beliefs? Let us then imagine the power of the other side, what it holds, what it maintains.
What is the point of all this, if not to reassure us, clinicians, in our knowledge, beliefs, techniques, behaviors?
At what point do we greet our patients, as Engel did, with a simple but concerned "How are you?" and let them tell us what is wrong and what they would like to get right.
To better understand this model, to take the best possible care of the patients who call on us, to better understand all the components of who they are, we need to train ourselves. To challenge ourselves. To shake up our beliefs and our knowledge in order to feed ourselves with the production of knowledge made possible by research.
List of References and Materials:
This blog post does not claim to produce knowledge, its writing is enabled by reading scientific publications, blog posts and other writings.
Laszlo, E. (1975). The meaning and significance of general system theory. Journal of the society for general systemes research. https://doi.org/10.1002/bs.3830200103
Brody, H. (1973). The Systems View of Man: Implications for Medicine, Science, and Ethics. Perspectives in Biology and Medicine, 17(1), 71–92. doi:10.1353/pbm.1973.0007
Laszlo, E. The Systems View of the World: The Natural Philosophy of the New Developments in the Sciences Paperback – April 1, 1972
Engel, G. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196(4286), 129–136. doi:10.1126/science.847460
Wade, D. T., & Halligan, P. W. (2017). The biopsychosocial model of illness: a model whose time has come. Clinical Rehabilitation, 31(8), 995–1004. doi:10.1177/0269215517709890
Mescouto, K., Olson, R. E., Hodges, P. W., & Setchell, J. (2020). A critical review of the biopsychosocial model of low back pain care: time for a new approach? Disability and Rehabilitation, 1–15. doi:10.1080/09638288.2020.1851783
[1] Laszlo, E. (1975). The meaning and significance of general system theory. Journal of the society for general systemes research. https://doi.org/10.1002/bs.3830200103 [2] Brody, H. (1973). The Systems View of Man: Implications for Medicine, Science, and Ethics. Perspectives in Biology and Medicine, 17(1), 71–92. doi:10.1353/pbm.1973.0007 [3] Laszlo, E. The Systems View of the World: The Natural Philosophy of the New Developments in the Sciences Paperback – April 1, 1972 [4] Engel, G. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196(4286), 129–136. doi:10.1126/science.847460
[5] Wade, D. T., & Halligan, P. W. (2017). The biopsychosocial model of illness: a model whose time has come. Clinical Rehabilitation, 31(8), 995–1004. doi:10.1177/0269215517709890
[6] Mescouto, K., Olson, R. E., Hodges, P. W., & Setchell, J. (2020). A critical review of the biopsychosocial model of low back pain care: time for a new approach? Disability and Rehabilitation, 1–15. doi:10.1080/09638288.2020.1851783