Open Access This book is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.
The images or other third party material in this book are included in the book's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the book's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.
Cover illustration: © Melisa Hasan
This Palgrave Pivot imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
The problem area of this essay is set within a broad trend of increasing recognition that crossdisciplinary approaches are needed for addressing the aetiology, prevention and management of diseases. The recognition of this need goes by the name of the ‘biopsychosocial model’, originally proposed by the physician and psychoanalyst George Engel in a paper published in 1977. By now, some 40 years on, 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. Notwithstanding its popularity, however, the biopsychosocial model has come to be seen as intellectually deficient. Recent commentary sees the biopsychosocial model as being handwaving, vague, lacking scientific validity and philosophical coherence. That the aspiring overarching framework of medicine is apparently at the same time so radically flawed signals a substantial problem in the conceptual foundations of contemporary medicine and healthcare. This is the problem we address in this book. We 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. While the task is focussed on the health sciences, it is set within the wider context of crossdisciplinary theory, research and problem-solving in contemporary life and human sciences.
Much evidence has emerged in the health sciences over the past few decades of psychosocial as well as biological factors being implicated in the aetiology, prognosis and clinical management of health conditions. Typically the relative involvement of the various kinds of factor depends on the specific condition, and on stage of condition. The biopsychosocial model has stood ready to accommodate this emerging evidence, a convenient depositary, but the conceptual task of clarifying the model appropriate for this new evidence is challenging. The conceptual challenge, recognised by Engel and contemporary commentary, is that there are historically deeply entrenched assumptions—physicalism, dualism and reductionism—to the effect that only material, physical and chemical causes are real, while distinctive psychological causes and social causes are impossible or incomprehensible. Against this background, the task of theorising biopsychosocial causal interactions in health and disease is non-trivial. The result we intend however is a model that can recognise psychological and social factors as being as real and as causal as muscle strength, biochemical reactions, molecular genes or brain circuitry.
Our 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’. These latter terms capture the idea that core scientific theory is not just accumulated data, but rather guides empirical research and interprets its findings. Core theory has an a priori quality, though in the context of shifting patterns and paradigms of knowledge, not absolute. What we customarily think of as philosophy on the other hand, and science on the other, merge together in the philosophical core of scientific theory. This was so in the mechanisation of the world-picture, which combined revolutionary science with ontological statements as to the primary causal qualities of nature, assigning cognition to an immaterial status with no or inexplicable causal power. In the radical changes that have been occurring in the life and human sciences over the past few decades we find new concepts, ontology and principles of change that do not so much solve old problems as disregard the terms in which they were constructed. For example the new models in cognitive neuroscience of embodied and embedded cognition replace the old mind/body dualism and its associated problems. New biological research programmes on genetic regulatory control of cellular metabolic processes complement but exceed the physical laws governing energy exchanges in making and breaking chemical bonds, hence effortlessly, as it were, circumventing the old idea that physics and chemistry say all there is to be said about causation. In short, the conceptual apparatus needed to theorise biology as involving a distinctive form of causation, and cognitive processes as biological, as well as in interaction with the environment, natural and social—is already in the science, as work in progress, and our purpose here is only to organise some key concepts and principles into a short core theory suitable for the biopsychosocial model of health, disease and healthcare. This core theory involves new concepts and models in the health sciences, such as those implicating chronic stress as a key mechanism linking adverse psychosocial factors to poor health outcomes.
The authors have mixed disciplinary backgrounds—DB in philosophy and clinical psychology; GG in medicine, neurosurgery, philosophy and bioethics. We have written this following many years of clinical experience, research and theorising. Biopsychosocial problem-solving is trans-disciplinary—the theory breaks down traditional boundaries.
This work was supported by the Wellcome Trust [grant reference 086071/Z/08/Z]. It represents independent research part funded by the National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.
Contents
About the Authors
Derek Bolton
is Professor of Philosophy and Psychopathology at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London. He read Moral Sciences and was awarded a Ph.D. in Philosophy at the University of Cambridge. His subsequent professional career was in clinical psychology at the Maudsley Hospital in London. He has published numerous papers in health sciences including on genetics and treatment of obsessive compulsive disorder, as well as in philosophy of psychiatry. He is the author of An Approach to Wittgenstein’s Philosophy , Macmillan, 1979, reprinted 2013; Mind, Meaning, and Mental Disorder: The Nature of Causal Explanation in Psychology and Psychiatry , with Jonathan Hill, 2e, 2004, and What Is Mental Disorder? An Essay in Philosophy, Science and Values , 2008.
Grant Gillett
is a Professor of Biomedical Ethics at the University of Otago and writes extensively on neuroethics as a sub-theme in neuro-philosophy. His professional career was in Neurosurgery and was punctuated by a D.Phil at Oxford University in philosophy of mind and metaethics. He has published in the philosophy literature on philosophy of mind and language, philosophy of medicine (particularly psychiatry), and the philosophy of medical and social sciences. He is the author of The Mind and Its Discontents, 2e, 2009; Subjectivity and Being Somebody: Human Identity and Neuroethics , 2008, and From Aristotle to Cognitive Neuroscience , 2018.