The Biopsychosocial Factor

Abstract

medical practice; rather in significant part it is engaged in special interest advocacy, pursuing and preserving social power’ [ 5 , p. 11]. How could Engel and Holman identify the dangers of special interest groups, as they are sadly known these days [6] , in the 1970s is astonishing. Biomedical reductionism is the key to the success of pharmaceutical propaganda [6] , and not surprisingly psychosomatic medicine and its biopsychosocial message are ostracized by the medical journals that are most liable to commercial influences. Another ‘dangerous’ part of Engel’s paper was concerned with the clinical inadequacy of the concept of disease, which has only become manifest in recent years [7, 8] . It has been argued that the time has come to abandon disease as the focus of medical care. Clinical decisionmaking for all patients should be addressed to attainment of individual goals and identification and treatment of all modifiable and non-biological factors, rather than solely on the diagnosis and treatment of individual diseases [7] . Clinimetrics, the science of clinical measurements, offers unprecedented opportunities for identifying such factors [8] . In psychiatry, exclusive reliance on diagnostic criteria has impoverished the clinical process and does not reflect the complex thinking that underlies decisions in psychiatric practice. The use of transfer stations with repeated assessments instead of diagnostic endpoints, the building of global formulations of clinical integration, staging methods, and a better organization of clinical information (encompassing subclinical distress, illness behavior, psychological well-being, and macroand micro-analyThe paper that George Engel published in Science in 1977 on the need for a new medical model [1] certainly attracted a lot of attention over the years [2] . It is generally seen as being concerned with the biopsychosocial model, which allows illness to be viewed as a result of interacting mechanisms at the cellular, tissue, organismic, interpersonal, and environmental levels. Accordingly, the study of every disease must include the individual, his/her body, and his/her surrounding environment as essential components of the total system [1, 2] . However, this was not the most important part of the paper and was not certainly new: for instance, Halliday’s book in 1948 [3] presented a similar model and Engel himself had written about this concept many years before [4] . The true challenge to biomedicine, as the subtitle implied, was carefully censored by the medical establishment in view of its dangerousness. Drawing from a paper by Holman [5] , Engel pointed to the alliance between commercial interests in medicine and biomedical reductionism leading to practices such as unnecessary hospitalization, overuse of drugs, excessive surgery, and inappropriate utilization of diagnostic tests. He wrote: ‘Professionalization has engendered a caste system among health care personnel and a peck order concerning what constitute appropriate areas for medical concern and care, with the most esoteric disorders at the top of the list’ [ 1 , p. 135]. And Engel quoted Holman who had previously written that ‘the medical establishment is not primarily engaged in the disinterested pursuit of knowledge and the translation of that knowledge into Received: August 13, 2011 Accepted after revision: August 25, 2011 Published online: November 22, 2011