Rebuilding Engel

Marks, David F. “Rebuilding Engel.” (2019): Theory & Psychology 0959354319884638.

Review of: Derek Bolton and Grant Gillett, The biopsychosocial model of health and disease: New philosophical and scientific developments. London, UK: Palgrave Pivot, 2019. 149 pp. ISBN 9783030118983

The authors, Derek Bolton and Grant Gillett, have mixed disciplinary backgrounds—Bolton in philosophy and clinical psychology; Gillett in medicine, neurosurgery, philosophy, and bioethics. They have written this book following many years of clinical experience, research, and theorising. They claim that “Biopsychosocial problem-solving is trans-disciplinary” (p. vii). Their work was supported in part by the Wellcome Trust at South London and Maudsley NHS Foundation Trust and King’s College London. For brevity’s sake, I refer to the biopsychosocial model as “BPSM.”

The lack of textual connections with psychology led me to wonder who the target audience for this book might be. The authors do not say. As far I can tell, there is nothing much here for the psychologist, nothing much for the medical doctor, nothing for the nurse, and slim pickings for the medical sociologist. One might surmise that the book is aimed at the philosopher of health and medicine (a fairly rare animal). Not keeping in mind any specific audience might mean that there isn’t one, save for the authors themselves and a few loyal chums with Christmas stockings to fill. In this case, mince pies might be kinder and easier to digest. More seriously, though, this book is definitely not light reading. However, it is a rewarding read which pays dividends for effort. I enjoyed it, and recommend it. Bolton and Gillett aim to:

“articulate a clear biopsychosocial model, drawing on Engel’s original, but updating it in the light of substantial developments in the sciences and philosophy in the past few decades. . . . [Their] methodology is to work with concepts and principles worked out in the sciences, but those of a fundamental theoretical status that borders into the ‘philosophical’ or even ‘metaphysical’” (pp. v–vi).

Metaphysics and medicine tend to make a fiery kind of cocktail. As if to add belt and braces, they speak of a “crisis” in the conceptual foundations of medicine and healthcare.(Another crisis? Does anything have to be a crisis before anybody pays attention?) The book’s rationale rests on the “vagueness” and lack of validity of the BPSM; that the BPSM is flawed. Both points are valid; others commented on the same things decades ago. Sociologist David Armstrong savaged the BPSM 30 years ago:

“Engel’s vision was of a social science subservient to the biomedical enterprise because he could not see that the ‘lesion’ or biological abnormality was anything but the very truth of illness. However he seemed unaware of sociological arguments which challenged this version of illness” (1987, p. 1214).

Bolton and Gillett overlook Armstrong’s critique. Sociology is not part of their brief. They ignore health psychology also. A psychology textbook, published 20 years ago, pointed out that Engel had left much unsaid (the point about vagueness) and, by some oversight, never actually defined the BPSM, leaving it open to interpretation, a medical kind of ink-blot test. The BPSM is not much more than a set of cosy beliefs and values in which to wrap a hard-boiled biomedical approach. Engel, so we thought, was serving old wine in new bottles and the BPSM wasn’t actually a model at all (Marks, Murray, Evans, & Willig, 2000, 2018).

I will briefly consider each of the four chapters, one by one. In Chapter 1, which concerns “The Biopsychosocial Model 40 Years On,” Bolton and Gillett consider that the model has a “reasonable claim to be the overarching framework for medicine and healthcare, invoked in clinical and health educational settings the world over” (p. v). They claim that the BPSM “has become the orthodox overarching model for health, disease and healthcare. It is much cited and taught in healthcare trainings of all sorts and in workshops and ward rounds the world over” (p. 5). Yet empirical evidence makes this claim somewhat doubtful, at least among the principal purveyors of the biomedical model, medical doctors themselves. Jaini and Lee (2015) found that the BPSM was being utilised in the curricula of only five U.S. medical schools. Nurse training, and the diverse array of para-medical fields, undoubtedly give the BPSM greater emphasis than medical curricula, but they probably always have because it serves their interest to do so. The greatest buy-in to the BPSM is in health psychology.

Setting aside the popularity issue, I return to the authors’ main theme in their first chapter, that the BPSM is an overarching theory of healthcare and the accusation of vagueness. Bolton and Gillett have a solution: “the scientific content and clinical utility of the BPSM is not to be found in general statements, but rather is specific to particular health conditions, and, further, specific to particular stages of particular health conditions” (p. 15). The authors seek a metaphor that allows a causal system of influence between the biological, psychological, and social levels of the BPSM. The metaphor, they suggest, must have a temporal, evolutionary, and developmental parameter. Now they are putting some meat, or soya, into the sandwich.

In Chapter 2, Bolton and Gillett argue that new concepts and principles of regulatory control apply in biology, and also run through the psychological and social domains. They argue that this enables a more unified science, and one that makes foundational differences between life and death, health and illness.

In Chapter 3, which is concerned with the issue of how “Psychology Regulates Activity in the Social World,” Bolton and Gillett argue that the core function of the psychological realm is agency. Few people would argue with that, except Dennett (2003), whose posture is that self and agency are delusions. Bolton and Gillett make a case that factors involved in health and disease “are increasingly seen to extend beyond the internal biological environment into the psychological, social, economic and political conditions of living” (p. 77). As if by fiat, the authors then argue that higher-level social factors are causal. I agree with them, but would have preferred proof of this and their Nobel Prize to follow, not energetic handwaving. At least, Bolton and Gillett set a clear agenda for making the BPSM a proper model.

Chapter 4 on “Biopsychosocial Conditions of Health and Disease” brings together the different strands of earlier chapters to discuss the major role of chronic stress in models of causal mechanisms linking psychosocial factors with biological damage, and spells out that “chronic stress is a quintessential biopsychosocial concept” (p. 109). Bolton and Gillett consider the Research Domain Criteria (RDoC) proposed by the N.I.M.H. for research in mental health as one illustration of a biopsychosocial research framework. In this, “Physical and mental health conditions are brought together in the new BPSM rather than being axiomatically separate—as they were in the old context of reductionism and dualism” (p. 109).

Measured against this goal, this engaging book mainly succeeds. One imagines that this excellent book will be read principally by the converted. In their next book, I hope that Bolton and Gillett will write a dumbed down version to convince medical doctors that the BPSM isn’t just one of “those topics” covered in the behavioural science course but a vital ingredient of their practice.

There can be little doubt that the medical model remains the dominant foundation of healthcare, and is likely to remain so. This book seems unlikely to change this any more than Engel.

References

Armstrong, D. (1987). Theoretical tensions in biopsychosocial medicine. Social Science & Medicine, 25(11), 1213–1218.

Dennett, D. C. (2003). The self as a responding—and responsible—artifact. Annals of the New York Academy of Sciences, 1001(1), 39–50.

Jaini, P. A., & Lee, J. S. H. (2015). A review of 21st century utility of a biopsychosocial model in United States medical school education. Journal of Lifestyle Medicine, 5(2), 49–59.

Marks, D. F., et al. (2000, 5th ed. 2018, 6th ed. 2021) Health psychology: Theory, research and practice. London: SAGE Publications.