Finding the System in the System

My comments on Jonathan Bolton’s apposite and thought-provoking paper are not those of a psychiatrist, but come from the opposite, physical end of the medical spectrum, that of manual medicine. Despite major differences in their modes of practice, both disciplines face challenging questions about how they are to understand and provide therapeutic support for patients.

The predominant problem in musculoskeletal medicine is pain, the understanding of which has seen significant developments recently, particularly the causal role that social and psychological factors play (Tracey and Mantyh 2007). These suggest that pain is not due simply to irritation of ‘pain’ nerve fibers that stimulate specific brain centers, but is a brain output in response to a perceived threat to which experience, expectation, interpretation and meaning all contribute. Not surprisingly, Engel’s Biopsychosocial model has been promoted heavily as an explanatory substratum, as it has in other areas of medicine. Exactly the same critical comments that Dr. Bolton makes in his paper can be applied to its use in manual medicine. However, it seems to me that the criticisms he makes and the major change in thinking that he advocates could be taken much further and have greater implications.

There are two main themes to the paper: the adequacy of the Biopsychosocial model as an advance on the biomedical and the role of diagnosis in clinical practice. The two are related in the superficial sense that diagnoses purport to explain an individual’s malady and that limiting the explanation to biological, predominantly physical factors, fails to account for many of the facts of the matter in an individual case. If a fuller range of factors is considered, it should make for a richer, more meaningful and relevant diagnosis. Although the theoretical account may indeed be richer and deeper, it is not clear why it should be more therapeutically effective. I want to suggest that an alternative strategy would be to uncouple them and to link the Biopsychosocial model to an understanding of health (or at least with illness) rather than with disease.

Engel’s Project

Dr. Bolton’s observation that the Biopsychosocial model is taught enthusiastically in medical schools but frugally applied in practice is just as true for manual medicine. His desire to understand why this is and to provide a remedy is, therefore, welcome. I fully support Engel’s motivation in proposing an alternative to the biomedical model and the broad direction in which he chose to go. If I have a criticism of Engel it is for choosing the term ‘Biopsychosocial’ to describe something that he went on to describe in terms of General Systems Theory (GST). But my main criticism is for the way the Biopsychosocial model has been misinterpreted and used, which has led, in my view, to many of the problems that Bolton quite rightly identifies.

In his famous 1977 paper on “The need for a new medical model: A challenge for biomedicine” (Engel 1977), Engel argues that illness is more than biophysical—that illness is a personal experience that additionally entails psychological and social factors. He acknowledges the problems inherent in reconciling the three ontologies and in his 1980 paper on “The clinical application of the biopsychosocial model” (Engel 1980), he argues more explicitly for a systems rather than relational approach to explain the complexities of health and illness along the lines that Paul Weiss and Ludwig von Bertalanffy had proposed for understanding biological phenomena. There are two key points in GST: the hierarchical and interdependent arrangements of open systems in which any given system is composed of subsystems and is itself part of a suprasystem, and the multifactoral nature of a system that makes it different from a simple relation (in which there are only two factors related to one another by some property). Engel’s argument is not just that health care’s concern should be with the individual person rather than a subsystem such as an organ or tissue, but that illness as a personal experience, can only be fully understood if all component elements in...