restricted access 4 A New Model of Medicine: George Engel’s Biopsychosocial Model
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chapter four A New Model of Medicine George Engel’s Biopsychosocial Model A theory is a reflection of the person who created it. George Engel, the person generally acknowledged as the founder of the biopsychosocial (BPS) model, once described how he, his twin brother, and his older brother, Lewis, were strongly in- fluenced by their uncle, Emanual Libman (1872–1946), a prominent New York physician (whose visitors and patients included Einstein, among others).“All three of us soon enough found ourselves preoccupied with figuring out just what it was he did and why he was so famous and sought after” (G. L. Engel 1992). Lewis became a scientist, not a doctor, later chair of biochemistry at Harvard. Engel notes that he and his twin brother, Frank, were more impressed by their uncle’s clinical reputation and reported skills than by his scientific reports. They both became doctors. Engel wondered whether the clinical aspects of medicine (as opposed to the more technical scientific parts), in which his uncle demonstrated such skill, could likewise be conducted scientifically. In 1941, when doing a research project with psychiatrist John Romano, Engel concluded that it was possible to take a scienti fic approach to the medical interview that might elucidate the human aspects of medicine. “From that time on my whole outlook, professional and scientific, was never again to be the same. The human dimensions of medicine had for me at last become accessible to scientific inquiry, just as had the heavens by the invention of the telescope. One could be scientific at the bedside after all!”(G. L. Engel 1992). This was at the source of Engel’s efforts with the BPS model: Engel wanted to make a science of the clinical bedside experience between doctor and patient. Whether he succeeded or not is at question. Engel the Internist Engel,whose theory is at the heart of modern psychiatry,was not a psychiatrist and never trained in psychiatry. He trained and practiced in internal medicine, with a special interest in gastrointestinal diseases. His first publications were about nerve metabolism,and his main interests had nothing to do with major mental illnesses.1 Indeed, in his early career, he was a self-proclaimed biological reductionist: “He dismissed most of what psychoanalytic psychiatrists had to say as ‘laughable’ and as ‘hogwash’” (Brown 2003). Even though he later became sympathetic to psychiatry and psychoanalysis, he never developed a strong interest in mental illnesses per se. In fact, “his main diagnosis of interest” was ulcerative colitis.2 Other areas of research were psychogenic pain and the effect of psychological states on gastric secretion in babies with gastric fistula. He wrote a book on fainting and two popular texts on “Psychological Development in Health and Disease,” and “The Clinical Approach to the Patient,” but nothing specifically on psychiatric conditions. (Of about 175 original articles and reviews, Engel never once wrote about mania or schizophrenia.) He attended the Johns Hopkins University medical school in the 1930s, an era in which the iconic influence of William Osler was vivid. Like Osler, Engel’s most important early medical activity involved autopsies, arranged by his uncle with a prominent forensic pathologist (one summer Engel observed more than three hundred autopsies; Ader and Schmale 1980). Whereas Osler used this experience to popularize the “clinicopathological” method in medicine and to introduce an organ-based, disease-oriented science to medicine, Engel went in the other direction, emphasizing, with his BPS model, the importance of the clinical interaction above laboratory tests or pathological examination. Engel the Psychoanalyst In the 1940s, Engel met psychiatrist John Romano in the course of his training; he would follow Romano throughout his career, first when Romano became chairman of psychiatry at the University of Cincinnati and later at the University of A New Model of Medicine 39 Rochester (where Engel spent the bulk of his life). Encouraged by Romano, Engel took an interest in the psychological aspects of gastrointestinal illness and, consequently , engaged in formal psychoanalytic training for five years in the 1950s in the Institute for Psychoanalysis in Chicago (which, run by Franz Alexander, was the center of psychosomatic medicine). Thus, Engel, the man, was an internist who sought to better understanding gastrointestinal illness through the use of psychoanalytic ideas. Some of his clinical views are clearly outdated due to their psychoanalytic orthodoxy: For instance, in 1956, he theorized that headaches in persons with ulcerative colitis were due to “strong...