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It ain't necessarily so: the many faces of the biopsychosocial model.

It ain't necessarily so, It ain't necessarily so. De t'ings dat you li'ble To read in de Bible--It ain't necessarily so.--George and Ira Gershwin and DuBose Heyward, Porgy and Bess (1934)

In this article the author provides a critical reflection on the actual application of the biopsychosocial (BPS) model in practice. The BPS model is considered both as a scientific construct and as a cultural phenomenon. With respect to the latter, the author explores ways in which the BPS model is used or adapted in clinical teaching and practice. Further, there are multiple understandings as to what constitutes the BPS model, for instance, whether ethical and relational considerations are extensions of the model or are distinct from it. The author considers the BPS model in action as variously a clinical ideology, a mandatory "party line," a tool for the exercise of political power, a philosophy that is not uniformly applied over time and an educational "add-on" rather than truly mutative.

Keywords: biopsychosocial model, culture, ideology

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It will be my argument in this brief article that "the" biopsychosocial (BPS) model is not singular, but plural, both in theory and practice. In part, I will explore the BPS model and its vicissitudes as much a cultural phenomenon as it is a scientific theory. My guiding metaphor will be Akira Kurosawa's classic 1950 movie, Rashomon (Criterion Collection, 2002), in which a rape and a murder are told from four different viewpoints. Truth is elusive, and understanding from perspective(s) is a necessary starting place.

My point is not the ultimate subjectivity of truth (relativism), but the need to recognize multiple narratives of truth (relativity). I apply the approach of reflective practice to BPS thought and work. Although I am a partisan of the BPS model in its most inclusive, integrative, and relational sense, I approach here the acculturation of the BPS model in medical science and practice naturalistically. That is, I shall attend to some of the culture historical vicissitudes of the BPS model after it left the hands of George Engel.

Historically, it is essential (and ironic) to remember that by 1977, when George Engel published his celebrated paper in Science advancing the BPS model, mainstream American psychiatry was already retreating from, if not repudiating, its brief liaison with behavioral science and becoming increasingly biomedical (largely pharmacological). The cultural lure of what many in American biomedicine call "real science" or "hard science" promised higher status than anything associated with the "softer" behavioral and social sciences. Even practitioners of family medicine--many of whose early leaders embraced an integrative model that encompassed the patient's personality, family, culture, community, and relationship with the physician--have not escaped this intense gravitational pull.

In their recent elaborations of BPS thinking and practice, Frankel, Quill, and McDaniel (2003) and Borrell-Carrio, Suchman, and Epstein (2004) contended that the BPS model is both (a) a philosophy and instrument of scientific inquiry and (b) a philosophy and instrument of ethical, compassionate, clinical relationships. Stated differently, in this view, the BPS model encompasses both what a physician could do and what a physician should do. Here, the BPS model is descriptive and prescriptive.

Brody (1999), however, sees the BPS model and patient-centered models as distinct and complementary. To Brody, the BPS model is instrumental, whereas patient-centered models are relationship-focused. Brody writes: "The biopsychosocial (BPS) model was originally proposed as a scientific paradigm and as such, aims to be ethically neutral to the extent that any scientific model or theory can be" (1999, p. 585). By contrast, patient-centered models "include both scientific and ethical aspects and claim to integrate those 2 elements of good medical practice" (p. 585). "In an extreme case, a physician could use the BPS model as a superior way to manipulate or coerce patients, since knowing more about the patients' emotions, cultures, and so on could render them more vulnerable to the physician's machinations" (1999, p. 585).

By yet further contrast, Frankel et al. (2003) and Borrell-Carrio et al. (2004) argue that the biopsychosocial approach to clinical practice is in fact a relationship-centered, rather than exclusively patient centered, endeavor and that the relevant relationships often extend far beyond the physician-patient dyad. Finally, the BPS model can be viewed as evolving rather than static, born fully developed, and unchanging. For example, Borrell-Carrio et el. proposed a "biopsychosocially oriented clinical practice" (2004, p. 579) that implements the BPS model.

THE BIOPSYCHOSOCIAL MODEL AND ITS CONTEXTS

In this section, I explore some uses to which the BPS model is put in various contexts. In my experience as a clinically applied medical anthropologist, employed in a family medicine department for 28 years, I cannot locate these uses on a simple continuum, for instance, as in a "greater" or "lesser" use of the BPS model as an ideal type. For example, in one understanding, seen as a professional ideal, the BPS model is something to be used with every patient, whatever the disease--or at least is sufficiently part of the clinician's self that it could be potentially used with every patient.

The BPS model as a clinical ideology is also used as a professional "tribal" boundary delineator. It is as if to say, "We [for example, family physicians] practice by the BPS model, but you [insert name of subspecialist] do not. You are narrowly biomedical." The boundary is also used to distinguish between good (us) and bad (them). At the same time, it should be recognized that the claim of living according to the BPS model is not the same as the actual practice.

For some (I dare say, many), the BPS is variously a shibboleth, a slogan, a "party line," a linguistic uniform, and a strategic code word that is invoked politically and is used tactically in grantsmanship to attract funding. In some BPS intellectual and professional circles, it is outre to admit to being strictly organic. To do so, one would be a philosophical outcast. To be accepted in a particular medical department or in a conversation at a medical convention, one might feel obligated to say that he or she teaches and practices biopsychosocially. To work in such an interpersonal atmosphere is tantamount to "passing" ethnically or racially in mainstream American culture. At their worst, these examples have in common the quality of sham. Incantation of ideological formulas is not the same as lived clinical realities. Conversely, during the height of the Cold War with the Soviet Union, a family physician colleague who truly aspired to think and work biopsychosocially (in both the philosophical and ethical sense) told me that he feared saying so openly. "What would I call myself, a biopsychosocialist?" he said with a mixture of whimsy and agony.

The question arises, Whose life, whose contexts, should be approached biopsychosocially? As I read Engel's article, the original answer was that the physician should try to understand and work with the patient biopsychosocially. More recently, some researchers, teachers, and practitioners are coming to view all participants in the clinical relationship, including the doctor-patient relationship itself, biopsychosocially (e.g., Stein, 1985; Stein & Apprey, 1985, 1990).

Operationally, the BPS model is not always consistently applied over time. In my experience as a participant observer in family medicine clinics, the BPS model is practiced differently on Friday afternoon (when the clinic waiting room is packed with patients who want to be well for the coming weekend and when all clinic personnel cannot wait for the workday to be over) from the way it is practiced, say, on Tuesday afternoon. Even the practice of the biomedical model is different in these differing temporal contexts! The physician is more likely to quickly prescribe an antibiotic on a late Friday afternoon for a condition/patient for which he or she would be far more hesitant to do so on Tuesday.

In contrast with the ideal practices of the BPS model identified earlier, the BPS model can be invoked and used to silence other voices if not banish other viewpoints in the name of "our corporate mission." For example, in one clinical department during the mid-1980s, several family theorists and therapists were brought in by the chairman in hopes of revolutionizing the practice of family medicine and revitalizing his department. They were especially fond of Salvador Minuchin's family theories and therapeutic methods that had wide currency at the time. In the name of advancing the BPS model of family-centered patient care, psychological, cultural, occupational, community, and epidemiological dimensions of health care were made unwelcome. In this circumstance, the curiosity and inclusiveness of perspective that are the hallmarks of science and of compassionate patient care (Brody, 1999) were negated and in their place was established a kind of exclusive clinical totalitarianism. In the guise of advancing the BPS model, power supplanted science and decreed which "science" was to prevail.

Another dimension of the BPS model in practice is the matter of whether it is treated as an "add-on" or is truly mutative in teaching, research, and clinical work. I have seen the BPS model adopted or coopted so that its routinized quality is of "more of the same" in biomedicine rather than a genuine reframing of medical thinking and working. This approach is in part adaptive to the time pressure of corporate health care and partly reflective of the personal preference of the physician. Although the BPS model is invoked, here its practice is entirely mechanistic and linear. Many harried family physicians have said to me over the last two decades: "Who has time for the luxury of the BPS model when we have to see as many patients as possible in a clinic session? We barely have time to treat the disease let alone to inquire into the patient's psychosocial situation."

CONCLUSIONS

In this brief article, I have surveyed a range of ways in which the BPS model has been conceptualized, extended, developed, used, adapted and, in some instances, negated. Alas, even ideologically, "the" BPS model is plural rather than singular.

In reflectively approaching BPS thought and practice, I have situated it culturally and historically. It is my hope that this exercise will assist us in thinking critically about any disciplinary doctrine, both as it is articulated in theory and as it is enacted in practice.

REFERENCES

Borrell-Carrio, F., Suchman, A. L., & Epstein, R. M. (2004). The biopsychosocial model 25 years later: Principles, practice, and scientific inquiry. Annals of Family Medicine, 2, 576-582.

Brody, H. (1999). The biopsychosocial model, patient-centered care, and culturally sensitive practice. The Journal of Family Practice, 48, 585-587.

Engel, G. (1977, April 8). The need for a new medical model: A challenge for biomedicine. Science, 196, 129-136.

Frankel, R. M., Quill, T. E., & McDaniel, S. H. (Eds.). (2003). The biopsychosocial approach: Past, present, future. Rochester, NY: University of Rochester Press.

Stein, H. F. (1985). The psychodynamics of medical practice. Berkeley: University of California Press.

Stein, H. F., & Apprey, M. (1985). Context and dynamics in clinical knowledge. Charlottesville: University Press of Virginia.

Stein, H. F., & Apprey, M. (1990). Clinical stories and their translations. Charlottesville: University Press of Virginia.

Howard F. Stein, PhD, Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center.

Correspondence concerning this article should be addressed to Howard Stein, PhD, 900 NE 10th Street, Oklahoma City, Oklahoma 73104. E-mail: howardstein@ouhsc.edu
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Title Annotation:a way of looking at the mind and body of a patient
Author:Stein, Howard F.
Publication:Families, Systems & Health
Geographic Code:1USA
Date:Dec 22, 2005
Words:1873
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