The biopsychosocial model: A response to Shakespeare,Watson and Alghaib (2017)

I was rather surprised to read Shakespeare et al.’s claim that the Waddell-Aylward ‘Biopsychosocial model’ is ‘largely unexamined within academic literature’ (Shakespeare, Watson and Alghaib, 2017). My own academic critique of the ‘biopsychosocial model’ (of which the ‘Waddell Aylward’ model can be argued as merely a version) was published in 2012, as part of my critique of psychogenic explanations for physical impairments (Kennedy, 2012a). Indeed, within the book I have also referenced other previous critiques of the biopsychosocial ‘model’ or ‘approach’ which can be said also to be ‘academic’, such as from Davey Smith (2005) and Epstein and Borrell-Carrio (2005). I myself also wrote a response to Mansell Aylward about the issue which was published on the website of the disability rights group Black Triangle (Kennedy, 2012b).

I would therefore argue that the biopsychosocial model has not gone ‘largely unexamined’ within academic discourse. Even while I personally may be judged by some as a ‘disability activist’, when I published the book in 2012 I had an academic position, and my arguments are based on academic research and analytical methods. It is, of course, perfectly possible that one can be both a ‘disability activist’ and an ‘academic’.

While Shakespeare et al.’s article has provided a welcome exposition of key uses of the biopsychosocial model to practise what can be argued as a form of ‘disability denial’ in social and ‘welfare’ policy, it does need to be remembered that the biopsychosocial model was initially driven by medics, including Waddell and Aylward themselves, and first used (to adverse effect) in health-care settings. There have therefore been academic critiques of the biopsychosocial model in this context, and unfortunately Shakespeare et al.’s comments could end up misleading the reader as to the academic work that has already been undertaken with regard to critiquing the biopsychosocial model per se.

As in my article for Black Triangle, my critique of ‘biopsychosocial’ models can be summarised (briefly and broadly) as follows. A ‘biopsychosocial model’ of medicine was proposed by George Engel in 1977. It is often claimed that ‘biopsychosocial’ approaches are merely ‘holistic’ approaches to people’s health, a much-needed move away from the ‘medical model’. In this context, objections to the model by patients (of which there have been many) might seem rather odd. Why would patients seek to move away from being seen as ‘whole persons’, in all their social and psychological complexity, and from being cared for ‘holistically’?

To answer these questions, one needs to consider Engel’s 1977 paper. Here Engel actually does not address the issue of psycho-social impact of illness at all, but merely argues that ‘psycho-social’ factors cause illnesses as diverse as diabetes and schizophrenia. Engel (1977: 132) takes the medical fact that, in diabetes, keto-acidosis and hypoglycaemia (physiological conditions in diabetes) may sometimes cause psychological symptoms, he then makes the fallacious argument that it therefore follows that signs and symptoms associated with diabetes are symptoms of ‘psychological distress’. He also fallaciously assumes that, because physical illness is experienced in psychological, behavioural and social ways by humans, this also means that therefore signs and symptoms of diabetes are caused by ‘psychological distress’. Engel’s paper therefore does not adopt a ‘holistic’ approach, but merely proffers psychogenic explanations for organic illnesses; even uncontested organic impairments such as diabetes.

Lack of concern about the impact of physical impairment is also evident in the responses to the draft NICE guidelines for chronic fatigue syndrome (CFS) or myalgic encephalomyelitis (ME), made by the ‘CFS/ME’ ¹ department at St Bartholomew’s Hospital (where key proponents of ‘biopsychosocial’ approaches such as Peter White practise). This department objected to providing blue badges and wheelchairs to people diagnosed with ME or CFS, and, responding to the issue of management of physical and emotional impact of such patients’ symptoms, commented: ‘The emphasis here would be appropriate for someone suffering from an incurable chronic disease, which CFS/ME is most often not.’ ²

Apart from the research (detailed in my book) indicating chronicity and poor prognosis in people diagnosed with ME and CFS, and the classification by the WHO ICD-10 of both terms as denoting a neurological disease, the response by the St Bartholomew’s Hospital ‘CFS/ME’ department is particularly remarkable, considering the research (discussed in Kennedy, 2012a) demonstrating that people diagnosed with this illness have a high level of physical impairment and ‘disability’, and can suffer more impairment than those with multiple sclerosis, end-stage renal disease and heart disease. It is fair to argue that sickness/impairment impact (physical, psychological, and social) is a key problem for people diagnosed with ME or CFS.

Contributors to the book Biopsychosocial Medicine (White, 2005) also promote psychogenic explanations of aetiology in illness, while neglecting to address the impact of physical illness, a topic conspicuous by its absence. White also claims the biopsychosocial approach as ‘better established’ for ‘medically unexplained symptoms’ (2005: 12–13), indicating it is most often used as a default psychogenic explanation for difficult to diagnose physical impairments. As Mary Horton-Solway (2002: 417) comments: ‘The use of bio-psycho-social reasoning appears somewhat different from the theoretical vision of a holistic disease-process model … .’

As discussed in my book, patients facing a ‘biopsychosocial approach’ therefore most often find themselves facing an overemphasis on the ‘psycho’ (and only then with regard to alleged causation, rather than impact, of their illness), at the expense of the ‘bio’ and ‘social’ aspects of their illness, leading to ‘psychogenic dismissal’ (Mackarness, 1980) of their physical impairments, and malign constructions of their characters (as hypochondriacs, malingerers, wimps). Whatever the ostensible holistic ‘treating the patient as a whole person’ philosophy claimed by proponents of ‘biopsychosocial’ approaches, they are used most often to assume that a physical illness is caused by psychopathology and deviance, and to advocate treatment/management approaches based on this belief.

Aylward’s and others’ professed distaste for the ‘medical model’ (as cited in Kennedy, 2012b) is remarkable, when many patients have come to actively seek to reduce medical inquiry to their physical bodies. This is most likely to be a rational attempt to prevent iatrogenic risks to their physical, psychological and social health caused by an approach that is not holistic at all, but, in real-world practice, an irrational psychogenic dismissal (and disability denial), by health professionals (and now agents of government social and ‘welfare’ policy), of physical illness, a phenomenon that has a fundamentally adverse impact on people suffering such impairments. Indeed, I would argue that the ‘biopsychosocial model’, whether practised in medicine or social and ‘welfare’ policy, is, when considered under a social model of disability (Oliver, 2013), a key cause, a driver, of ‘disability’ in itself.