~ Annals ot l'3IIlUY lVleulCll1t:- '"'V1U1..'"'u ¿ _ _u___

Biopsychosocial ModelJoseph E Scherger (7 December 2004)

V' Welcome contributionShmuel Reis (6 December 2004) .

Engel's LegacyDiego Gracia (5 December 2004)

.. Perambulations on: -"The Biopsychosocial Model25 Years LaterEugene S. Farley (3 December2004)

Epistemology, politics¡ emotions and countertransference: Around "The BiopsychosocialModel 25 Years Later: Principies, Practiceand Scient.ific Inquiry".

Jorge L. Tizón,SpainMentalHealthDirector

Send response tojournal:Re: Eoistemoloav.oolitics. emotions andcounter transference:Around "TheBiopsvchosocial Model25 Years Later:Princioles. Practice andSclentific Inauirv".

Email Jorge L. Tizón

17áo. .March2005

- "'" .The excellent ánd well-documented work presented bydoctors Borrell- Carrió, Suchman, and Epstein (1) has themerit to introduce rigorously and radically the discussionabout the current prevalence and validity of the modelproposed by Engel 2S years ago. Thus, since the workmerits it, and without trying to be too systematic in mycommentary, 1 would like to add a series of contributions.

First, 1 think that today, it is worthwhile to re-examinethe model with an open mind taking a serious and well-founded perspective as these authors do. The title of theirwork can give us an idea of that in-depth examination~bfthe topic: principies, research, and practice.

And to join in the discussion, I would say that today;

1') The Biopsychosocial model is being applied neither at ascientific nor technicallevel except in very limited circles,at least in the technologically developed countries in theworld. 2) Although there are worthwhile groups andorganizations that try to develop it at a clinical andpractice level, 3) its principies continue to be reiterated,although they should be revised and updated from thefour-sided perspective of every scientific or technologicaldiscipline of the model: theoretical, technical,epistemological and practicar or pragmatic. 4) The modelhas a limited application today in scientific research,except in the field of primary careo S) It calls specialattention to the lack of theoretical and technicalapplication in the field of mental health.

It is my understanding that the causes for this situationwould have to sought in: 1) The biases of extremebiological reductionism that are re-emerging in thedifferent specialties in medicine. 2) Extremelymechanistic theoretical and epistemological empiricism ofthis theoretical re-imposition.

In a first approximation, both phenomena can only beexplained by:

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a) A decrease in the mental abilities of the doctors andresearchers in the field ~f medicine and health careo b) Acultural and id,eologicalimposition and even of a powerderived from the dominati.on of the medical-industrialcomplex. Today, the imposition ofthese not only invadeshealth care, but also the critical thinking capabilities,autonomous ethics and dinical approach to theconsultation process of a great part of our teachers,administrators and researchers.

Since it can be foreseen, I emphasize (provisionally) thesecond hypothesis to explain to myself that abnormal re-introduction of the "one- dimensional thinking" embodiedby the triple biological reductionism, the mechanisticempiricism and the "health care free trade". Atheoreticaltrilogy and diametrically opposed to Engel's proposal, ofcourse.

However,lharideological and social reality is impedingus, as far as I know, from executing the application of thebiopsychosocial model in broader, less limited circles.Also, it is impeding us from performing a critical re-evaluation.

Along the lines of the authors, I would propose a re-evaluation in those four fields that categorize anyscientific or technical discipline: theoretical, technical,practical and epistemological: I will provide some of myviews in those areas:

1) In the epistemological and theoretical area

1) As the authors indicate, Engel was quite radical whenhe criticized the dualistic nature of modern medicine. ButtOday, the concept is expanding and the practice of"biomedicine", a way, as far as I know, of radicalizing itsbiological content, in a consequent anti-Engel spirit.

2) In terms of the materialist reductionism criticized byEngel- in a way that today we could understand assomething na"ive- is even more omnipresent, and in aneven more reductionist version. The "gene" is pursued toexplain each iIIness, trauma or even individual and socialbehavior, because once that agent is found "everythingwill be resolved". How many "holistic", "global","biopsychosocial", "anthropological" and other thoughtsare thrown overboard in the process?

3) The influence of the observer in what is observed wasin its time an excellent remembrance of Engel, who reliedon the pioneering contributions about the topic - inchronological order - psychoanalysis, physics of relativity,cybernetics and general theory of systems. However, weare further away from having developed, with any depth,at a theoretical and technical level, this epistemologicalperspective.

According to my understanding, at that theoretical and

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epistemological levelt the consequent development of thebiopsychosocial model would suggest today at least thefollowing ideas:

1) The development of the epistemological model, basedon contemporary epistemologies, such as the "non-representative realism", "critical realism" or"constructivism" .

AIItheoretical approaches insist that in our approximationto the knowledge of any reality, we must take into

. account the.study of its genesis as of its structure, as wellas the subje~t-object relationship that we establish in itsknowledge. More reason to do it in the field oftechnologies of health careo 1 have, in my writings, triedto apply those post-empirical epistemologies, initiallydeveloped by Popper, Piaget and later by authors such asBurge, Cha-Imersand others (2), to the field of mentalhealth then, to the field of primary careo Without muchsuccess, of course: The forces that have impededsufficient development of the application of thebiopsychosocial model in the case of authors and expertssuch as Engel tend to be more directed toward authorsand experts, but much less relevant to and at theperiphery of the Empire.

2) The development of the biopsychosocial model impliesan intrepid work to the re-instatement of models that aremore globalizing and anti- reductionist in the theory ahdpractice of today's medicine. That activity of theoreticalexpansion will be impossible without actively combatingthe uninspiring pseudo-materialistic empiricism thatdominates it today.,3) And, it will be impossible without an active and ampleparticipation of the people in the profession, thepopulation and the politicians that may try, at an ethical,theoretical, clinical and politicallevel a re-formulation ofthat disturbing dominium that the pharmaceuticalindustry has extended to medicine and to contemporaryhealth careo 1 insist that on the political issue, in fact, it isabout a fight of power.

11)At a technical and pragmatic level, the authorspurpose seven principies to complete and develop themodelo 1think that in this part, they refer fundamentallyto the application of it, in other words, its practice. Thoseprincipies or pillars are:

1) Self-awareness (why not "insight"?) 2) Activedevelopment of the truth, 3) A new emotional style basedon emphatic curiosity, 4) Self- calibration to reduce gaps,5) Educating the emotions, 6) Use of informed intuition,7) Communication of clinical evidence to stimulate dialog,not only as a mere application of a protocolo

Starting with my basic agreement with these proposals, 1would like to combine them here with a series of

schematic contribotions:

I agree witll,.theauthors in that, a basic topic today in thestudy and practice of the supporting disciplines consists inhow to develop a theo,y and practice that ineludesemotions in the clinicai relationship. Howto introduce andto take advantage, in elinical practice, of emotionalfunctions such as solidarity, contention, hope, and trust.How to use them to maintain an efficient and effectivemedical attitude precisely because it is unifying, attentiveto the relationship. At an elementallevel, I tried to makea series of concrete proposals for years, and I also

. proposeda qualificationfor that manner of exercisingmedicine: "health care centered on the care-seeker" (3)an application and development of the model of Balint of"patient-centered medicine" (4) furthermore, the modelcan be expanded to "health care centered on the care-seeker (while member of a community)" (5). A basicelerñent'ln"'that tradition is the introduction and re-introduction in the biopsychosocial model of the basicpsychoanalytical contribution. In fact, for complexproblems of scientific empirism and of struggles of power,I think today, psychoanalysis is excessively isolated frommedical theory and practice. However, it is precisely thetechnological orientation that has most taken account thestudy and the technical use of emotions and attitudes ofhealth care personnel and of the mutual emotionalinfluences between clinician and the care-seeker. Thestruggles of power between the theorists in technical-behaviorist and systems approaches againstpsychoanalysis (and vice versa) have impeded the pursuitof the potentialities of the latter in this field; today thosecontributions have greater potential precisely beca use ofthe importance that the interpersonalists andintersubjectists possess in modern psychoanalysis..;

Precisely, a consequence of the application of the modelof Engel and of the seven proposed principies by Borrellet aL, would be to force an improvement in our systemsof education of health care personnel taking into accountthis relational constructivist, intersubjective perspective.This would involve, for example, an increase in thepractice of diverse types of personal therapy for clinicaldoctors, as much to promote their self-knowledge anddominium of their own blind spots as to facilitate apersonal livelihoodof the processes of psychologicalchange that could later be applied to its clinical practice. Iam referring here, for example, to personalpsychotherapy, to group psychotherapy and grouptechniques, to specific techniques such as "grief groups"or "reflection groups" and "Balint groups", etc. that haveproved for many years of their potential to increase thecapacities of emotional awareness (as much about theprofessionals themselves as of the consultants). Suchtechniques, combined with others that are morecognitive, could be basic in maintenance and improveseveral of the aspects of the proposed changed by Borrellet al.: Seen in depth, several of such principies are foundconnected with countertransference, if we utilize a

schematic contribotions:

I agree with the authors in that, a basic topic today in thestudy and practice of the supporting disciplines consists inhow to develop a theorY and practice that includesemotions in the clinicai relationship. Howto introduce andto take advantage, in clinical practice, of emotionalfunctions such as solidarity, contention, hope, and trust.How to use them to maintain an efficient and effectivemedical attitude precisely because it is unifying, attentiveto the relationship. At an elementallevel, I tried to makea series of concrete proposals for years, and I also

- proposed a qualificationfor that manner of exercisingmedicine: "health care centered on the care-seeker" (3)an application and development of the model of Balint of"patient-centered medicine" (4) furthermore, the modelcan be expanded to "health care centered on the care-seeker (while member of a community)" (5). A basicelemEmn-n"'thattradition is the introduction and re-introduction in the biopsychosocial model of the basicpsychoanalytical contribution. In fact, for complexproblems of sdentific empirism and of struggles of power,I think today, psychoanalysis is excessively isolated frommedical theory and practice. However, it is precisely thetechnological orientation that has most taken account thestudy and the technical use of emotions and attitudes ofhealth care personnel and of the mutual emotionalinfluences between clinician and the care-seeker. Thestruggles of power between the theorists in technical-behaviorist and systems approaches againstpsychoanalysis (and vice versa) have impeded the pursuitof the potentialities of the latter in this field; today thosecontributions have greater potential precisely beca use ofthe importance that the interpersonalists andintersubjectists possess in modern psychoanalysis..;

Precisely, a consequence of the application of the modelof Engel and of the seven proposed principies by Borrellet al., would be to force an improvement in our systemsof education of health care personnel taking into accountthis relational constructivist, intersubjective perspective.This would involve, for example, an increase in thepractice of diverse types of personal therapy for clinicaldoctors, as much to promote their self-knowledge anddominium of their own blind spots as to facilitate apersonal livelihoodof the processes of psychologicalchange that could later be applied to its clinical practice. Iam referring here, for example, to personalpsychotherapy, to group psychotherapy and grouptechniques, to specific techniques such as "grief groups"or "reflection groups" and "Balint groups", etc. that haveproved for many years of their potential to increase thecapacities of emotional awareness (as much about theprofessionals themselves as of the consultants). Suchtechniques, combined with others that are morecognitive, could be basic in maintenance and improveseveral of the aspects of the proposed changed by Borrellet al.: Seen in depth, several of such principies are foundconnected with countertransference, if we utilize a

traditional concepto Firmly, the principies that the authorsenumerate and label as (1) self- awareness (2) activedevelopment of the truth (3) an emotional style based onemphatic curiosity (4) self-calibration to reduce biasesand (5) education of emotions. Five of its seven principieshave to do, as I understand, with the ability to use one'sown emotions, feelings, attitudes and ethics (ability thatis based, or course, in the ability to be in contact withthem, in other worcls, in the ability of "insight").

And all of them, without forgetting the political andorganizational context that has changed in an importantway from the proposals of Engel: for example, a greatpart of the present and future care is being done ingroups, in teams. This means obvious changes not only inthe extemal setting of our practice, but also in theinternal setting. On the other hand, at a politicallevel,the advancement of certain health systems in the worldseems evident. With time, its bureaucratic excesses willtry to remedy themselves through the introduction ofintemal competition, the competition with the privatesector and certain principies of the market. But newunresolved problems emerge: for example, the tendencyof the private systems and the law of the private welfareto infect in different ways, those supposedly publicsystems. But this topic is too complex for us to be able toanalyze it in such a superficial way. Thus, I think I will becontent with mentioning it briefly and I give thanks againto the authors and the magazine "Annals of FamilyMedicine"for providing us the possibility of this opendiscussion.

References

1) Borrell-Carrio F, Suchman AL,Epstein R. TheBiopsychosocial Model25 Years Later: Principies, Practiceand Scientific Inquiry. Annals of Family Med 2004, 2 (6):576-582. 2) Tizón JL. Introducción a la epistemología dela psicopatología y la psiquiatría. Barcelona: Arie11978.3) Tizón JL. Componentes psicológicos de la prácticamédica. Barcelona: Biblaria 1999 (50 ed.) 4) Balint M.(1957) The Doctor, His Patient and The IIIness. London:Pitman 1957. (2a ed., enlarged: New York: InternationalUniversities Press, 1964) (Spanish translation: El médico,el paciente y la enfermedad. Buenos Aires: Libros Básicos1969). 5) Tizón JL. La atención primaria a la salud mental(APSM):Una concreción de la atención sanitaria centradaen el consultante. Atención Primaria 2000. 26,2: 111-119.

Competing interests: None declared