The Biopsychosocial approach provides an understanding

The Biopsychosocial Model

The definition of behavioral medicine implies that it is based on a biopsychosocial model of health and disease. The biopsychosocial model is a general model positing that biological, psychological (which includes thoughts, emotions, and behaviors), and social (e.g., socioeconomical, socioenvironmental, and cultural) factors, all play a significant role in health and disease. It follows, that health and disease are best understood in terms of a combination of biological, psychological, and social factors rather than purely in biological terms. This is in contrast to the biomedical model of medicine that suggests every disease process can be solely explained in terms of a deviation from normal function such as a physiological processes, infections, genes, developmental abnormalities, or injuries. In addition to behavioral medicine, the model is used in fields such as medicine, nursing, health psychology and sociology, and particularly in more specialist fields such as psychiatry, family therapy, clinical social work, and clinical psychology.

The model was developed by George L. Engel, a psychiatrist at the University of Rochester, and putatively discussed in an article published in 1977 in Science, where he posited “the need for a new medical model” (Engel, 1977). In an article published a few years later (Engel, 1980) he illustrates this model in detail by applying it to the fate of a hypothetical patient with coronary heart disease. In contrast to a classical biomedical approach, which focuses on the investigation of pathophysiological processes and the intervention at organ-, tissue-, and cell-level, biopsychosocial care would comprise a systematic (behavioral) analysis of typical personality traits and coping behaviors, which may impede admission to hospital in good time or impair medical treatment in any other way. For example, if personal ways of responding to a failed arterial puncture are not taken into consideration (e.g., fainting due to sympathetic hyperarousal), cardiac arrest may be the result. At the social level, the stabilizing role of partners and other forms of social support are also taken into account.

While behavioral medicine aims to include biopsychosocial aspects in research and treatment, there is often such a breadth of information at the individual (clinical) level that it is difficult to derive specific action strategies from it. Indeed, the biopsychosocial model has been criticized extensively for its lack of specificity that renders it untestable, according to some critics. Psychiatrist Niall McLaren summarizes his critique as follows: “Since the collapse of the 19th century models (psychoanalysis, biologism, and behaviorism), psychiatrists have been in search of a model that integrates the psyche and the soma. So keen has been their search that they embraced the so-called ‘biopsychosocial model’ without ever bothering to check its details. If, at any time over the last three decades, they had done so, they would have found it had none” (McLaren, 2006). In his view the biopsychosocial model should be viewed in its historical context as an alternative to biological reductionism, which was (and still is) dominating the medical sciences.

Levels of Analysis in Peace Psychology

Psychologists of all stripes appreciate traditional psychological analyses that draw on the multilevel, biopsychosocial model, in which events at one level may have multiple determinants within and across levels of analysis. To illustrate, traditional psychological analyses could examine violent intergroup behavior at the biological level of neurophysiological activity; as a property of cognitive and affective variables at the individual level of analysis; or at the level of social determinants, including interactions within and across levels. Peace psychologists have also drawn on the biopsychosocial model, though emphasis has been placed primarily on the psychosocial components of the model. For example, peace psychologists have explored personality characteristics associated with interpersonal peace, which has demonstrated some continuity across levels. People who have a highly agreeable disposition are more likely to engage in cooperation, helpfulness, and empathetic concern, and are less likely to elicit conflict than people who are low on the agreeability scale (Sims et al., 2013).

While appreciating the biopsychosocial model, peace psychologists are often even more transdisciplinary in their approach, drawing links between psychology and other disciplines including political science, sociology, cultural anthropology, and history, not unlike the field of Peace and Conflict Studies, which is the transdisciplinary home for many scholars and practitioners of peace. Indeed, when peace psychology became recognized among scholars during the Cold War, the field of international relations, a specialty in political science, played a dominant role in orienting peace psychologists to key concepts and themes. At the time, peace psychologists drew on many concepts at the macro level, such as nuclear deterrence, and added a psychological perspective (e.g., noting that the effectiveness of a policy-like deterrence depends on the perceptions of political leaders).

In addition, peace psychologists often prefer to have problems identified and framed by those who are experiencing them firsthand. For example, the “Global North” tends to focus on the problem of episodic violence, while the “Global South” is typically more concerned about structural violence. It follows that the kind of peacebuilding and cultural transformations that will be most relevant and efficacious vary depending on geohistorical context and the level(s) of analysis that is most germane to a given problem. Imposing universalized notions of the nature and scope of focal concerns without regard to geohistorical context has been called out as a form of epistemic violence, a pernicious form of cultural violence in which the nature of knowledge and its production are dominated by the Global North (Seedat et al., 2017).

The current escalation in tensions between Hindus and Muslims in South Asia illustrates the usefulness of a multilevel analysis that takes into account geohistorical context. Amid the decline of secularism, the Supreme Court's decision in 2019 to allow the construction of a Hindu temple on top of the ancient ruins of the Babri Mosque was seen as an endorsement of Hindu nationalism. Moreover, the Hindu-nationalist government revoked the semiautonomous status of the disputed region of Kashmir—a Muslim majority area. At the end of the year, the Parliament of India passed the Citizen Amendment Act (CMA), which provides a path to Indian citizenship for illegal migrants, except those who are Muslim. The recent riots in New Delhi left dozens dead as Hindu-nationalists attacked Muslims who were protesting the CMA. At the time of this writing, there is a new wave of violence against Muslims that is fueled by accusations that they are deliberately spreading the newly emerged coronavirus in restaurants, temples, and crowded areas. All of these events provide a thick geohistorical context that must be taken into account in the development of suitable peacebuilding interventions.

Comparing the ICF Model with Engel's Biopsychosocial Model

Because of the similarity in the label, it is tempting to compare the ICF ‘biopsychosocial model of functioning and disability’ with the approach famously offered up in 1977 by psychiatrist George Engel. As it happens, the similarity between the two models ends with the common label, and it is instructive to see why this is so.

In his 1977 presentation of his model, Engel's concern was to “provide a basis for understanding the determinants of disease and arriving at rational treatments and patterns of health care” (Engel, 1977, p. 196). His critique of the ‘biomedical model of disease’ was in part conceptual – rejecting its reductivism and tendency to dismiss nonbiomedical explanations as irrelevant – but was for the most part clinical or therapeutic. His biopsychosocial model was a plea for the scientific legitimacy of investigating nonbiological, or what we now call social determinants of disease (see Figure 2); yet all of his arguments focus on the single, purely clinical phenomena that patients seek medical help not merely because of experienced biological dysfunction, but also because of expectations about what it means to be healthy, expectations that are socially, culturally, and even linguistically, determined.

At one point, he argues that, biomedically, the state of grief has all the hallmarks of a disease – bodily and psychological disturbances and a predictable symptomatology and prognosis. But, significantly, grief is rarely so perceived because, socially and culturally, it is understood as a ‘problem of living’ not a disease. In short, patients acknowledge diseases only if they perceive them as sickness, and they will only do so within the framework provided by psychological and cultural expectations. The physician, Engel concludes, must therefore supplement her or his biomedical knowledge, with skill in social and psychological perceptiveness in all therapeutic encounters.

By contrast, the ICF does not offer any account of the determinants of disease or other health conditions, and for this reason alone the two models are radically different. But in addition, the ICF does not make any distinction between health states and the perception or feeling of being ‘sick.’ The ICF is a wholly objective, descriptive tool. Of course, it is evident that a person can have a disease and not feel sick, or feel sick and be perfectly healthy: this is a crucially important clinical realization that, as Engel argued, a responsible physician needs to take on board. But the distinction between health and sickness is irrelevant for the description of health states and the dimensions of functioning that can, in interaction with environmental factors, led to disability. Description, as a precondition for assessment and measurement, is the raison d'etre of the ICF.

Finally, it is not entirely accurate to say that the ICF utilizes a biopsychosocial model at all, at least one that bears a family resemblance to Engel's model of determinants of disease. In fact, although many of the environmental factors are social phenomena, many if not most environmental factors are physical things in the world – weather, buildings, elevators, and other people. It might have been better to use the terminology now becoming more common in the disability literature and naming the ICF model the ‘environmental’ or ‘interactive’ model.

Conclusion

The interconnection of psychological and GI functioning is evident in both organic and functional GI disorders, supporting the applicability of a biopsychosocial model for these chronic conditions. The relationship seems to be bidirectional, with each able to affect the other, although the etiological role of psychological distress in GI disease such as IBD remains to be elucidated. The findings from both animal and human studies in this area have contributed to new understandings of biological underpinnings in psychological processes. These interrelationships have opened up further directions for treatment of GI disorders, with positive findings from psychological interventions related to improvement of patient outcomes and reduction of health care utilization. Nevertheless, more rigorous treatment studies are needed to determine patients most apt to benefit, efficient modalities for treatment delivery, and protective effects for disease course. Continued research efforts regarding the role of stress and preexisting depression, particularly in inflammatory disease, are likely to increase the understanding of the mechanisms linking the psyche and GI disease, and perhaps will facilitate more widespread integration of biopsychosocial treatment in gastroenterology.

Mental Health and Recovery

The move toward more holistic frameworks for understanding why people's mental health deteriorates include the stress vulnerability model as mentioned above (Zubin and Spring, 1977), the biopsychosocial model (Engel, 1977, 1980), and the recovery model (Deegan, 1988; Anthony, 1993). The latter, in particular, reflects a recognition that modern day mental health practitioners increasingly need to adopt a ‘being with’ rather than ‘doing to’ approach when working with service users (Hinshelwood, 1998).

Interestingly, despite the advances in psychiatric treatments identified above long-term international studies of schizophrenia (Harrison et al., 2001; Jobe and Harrow, 2005) have found that medication makes little difference to symptoms in about a third of service users whilst another third will report a reduction in symptomatology that may be accompanied by a regaining of social and psychological functioning, sometimes without any medication. According to Romme and Escher (1989) who have pioneered work on voice hearing in the Netherlands, neuroleptic medication has little effect on voices heard by individuals with a diagnosis of schizophrenia but do reduce the anxiety and distress often provoked by the voices.

Similarly, of people diagnosed with bipolar disorder, around half report a recovery from symptoms usually within a 6 week period with nearly all achieving this within 2 years (Tohen et al., 2003). Unfortunately, for service users with this type of disorder relapse tends to affect more than half with individuals.

What these studies suggest to mental health social workers is that there will be times when individuals with mental health problems are well and will be better able to develop coping strategies for managing their symptoms that manifest when they are ill. This in effect is the essence of the ‘recovery model’ which acknowledges that individuals may continue to experience symptoms of mental distress whilst retaining a high degree of control over their lives.

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