101: 03. The Biopsychosocial Model
- Jul 29
- 8 min read
Infographic and concise guide of BPS theory.
The term biopsychosocial is referred to extensively in medicine and the community, especially regarding more controversial interpretations. For example, in the response from the Royal College of Psychiatrists to our open letter, they stated:
Psychiatrists are experts in the biopsychosocial model to understand all their patients needs and an suggestion that they shouldn’t debate illnesses with biological causes risks stigmatising patients. (Prof Lade Wade).
For an excellent analysis of what is problematic with this statement, please see the response from Dr Mark Harper and the Cambridge ME group.
To clearly name the problem: The term is accepted in medicine as a common-sense position that on the surface makes a great deal of sense. Yet, there is often a hidden psychosomatic interpretation that has led to significant patient harm.
An example of this is how the long-standing journal Psychosomatic Medicine was renamed to Biopsychosocial Science and Medicine, and The American Psychosomatic Society to the Society to Biopsychosocial Science and Medicine.
It is therefore important that the community understands what is meant by biopsychosocial, so it can be understood when the term is weaponised. We hope this 101 will help.
Origins
The biopsychosocial model was proposed by George L. Engel (not Marx’s buddy) in 1977 in The Need for a New Medical Model: A Challenge for Biomedicine. What is important to note is that it was a theoretical model, and there is always risk when theory is clinically applied without sufficient evidence.
Engel was an internist and Professor of Medicine and Psychiatry. In the 1940s he converted to the psychosomatic school after being initially skeptical. In the 50s, he was one of the major figures in psychosomatic studies, editing the Psychosomatic Medicine Journal and was prominent in the American Psychosomatic Society. With his colleague John Romano, the University of Rochester Medical Centre in New York became the leading centre in psychosomatic theory and training.
His speciality was functional (i.e. psychosomatic) gastrointestinal disorders, especially ulcerative colitis. Which hasn’t exactly aged well, seeing that the view of UC as psychosomatic has been firmly challenged and is now reclassified within inflammatory bowel disease.
He claimed that psychiatry was being threatened by a reductionist view, that all mental illness was biological and that it would be subsumed into medicine. It therefore had to choose between this reductionism or his expansionist model (handy!)
Although psychiatrist Roy Grinker came up with the term in the 1950s to emphasise the bio against psychoanalytic prominence. Engels established the theory but emphasised the psycho social in the biological.
Engels claimed inspiration from the general systems theory in biology, but what he essentially did was try to create a unified field model without the maths or proof. Yet it took the medical world by storm. It became the mainstream orthodoxy in psychiatry and strongly influenced general medicine—to the point of dogma.
Flaws of the Biopsychosocial Model
It is important to understand its fundamental flaws, as they directly impact patients when applied in clinical practice.
The first is that it has no clear ontological grounding. It never clarified how biological, psychological, and social levels relate, whether they are causal or descriptive. This caused huge problems for patients, as BPS factors were interpreted as causal, even if there was no decent evidence.
And this is a major problem of the BPS school—and why it refuses to die. It cannot be disproved because it is unfalsifiable. This lack of philosophical clarity, which Prof. Diane O’Leary critiques, leaves it conceptually unstable.
Yet still fifty years later, there is no evidence that the biopsychosocial model itself is a validated explanatory theory of disease or that applying it as such improves outcomes.
Engels did not give any criteria for explanatory priority. He designed it with inbuilt eclectic freedom that meant it was to be applied in all cases at all times. In other words, it is incredibly vague to the point of chaos. The physician can choose any explanation he likes. It became medicine’s “Do what thou wilt shall be the whole of the Law’.
This meant that there are no safeguards against premature psychological interference and no limit on psychogenic attribution—which has caused profound levels of harm to patients.
The Drift: From Framework to Explanatory Model
Here we get to the problem of when a model is applied because it sounds coherent but does not have conceptual grounding or pragmatic evidence. In essence, it’s trying to force a square through a round hole - and patients are squares that get their edges sheared off.
Engel’s BPS model moved from the area of theory to a lens for care and a causal explanation for illnesses whose pathology was poorly understood. We see this specifically through Engel’s psychosomatic work, Simon Wessely’s appropriation of the model for ME/CFS and its widespread adoption in chronic pain.
How it moved to a lens for care was that behavioural interventions were disproportionately positioned as disease-modifying. For example, CBT for ME/CFS and mindfulness and calming techniques for chronic pain.
This essentially transfers blame to the patient. As psychological factors are seen as influencing and/or causing biological illness—which is what psychosomatic medicine is. What the BPS terminology did was create a mask for psychogenic terminology so that patients and medical culture did not question its adoption.
The BPS model now acts like many of the vague, unproven physical theories that explained hysteria—like animal spirits by Willis or the reflex theory by Laycock. Emotions and mental states are seen as so intertwined with bodily processes that a rebranding of hysteria has occurred in a new and easily digestible form.
Benign Malevolence in Medical Culture
Here we come to the crux of the issue. In medical culture, the term biopsychosocial is associated with compassionate, inclusive, humane care. From a common-sense point of view, doctors should consider patients’ social situations and psychological distress. So, a blank look of disbelief often occurs when patients raise concerns.
The key problem is the conflation of interpretation and confusion with the social determinants of health model.
We have the common-sense interpretation. This is where the patient (of course) consists of interconnected factors: biological, psychological and social. Often taught in medical schools as a three-legged stool. That doctors should look beyond the patient as a biological machine, and often accepted without critique as it sounds compassionate, obvious and inclusive.
Yet, we also have the original, often forgotten, foundation of where the model was formed: the psychosomatic. This is where Engels and others smoothed BPS labelling over a very old hysterical bottle. Psychological and social factors take on causative force, producing symptoms but not necessarily disease. And behavioural change is given agency to reverse symptoms.
The critical issue is the conflation and mixing of these two interpretations. When a patient objects to the second, psychogenic model, the first, holistic model is used as a defence and ruse. This means critique of psychogenic causation gets reframed as opposition to holistic care or claims of stigmatisation.
Most clinicians believe they are endorsing the first statement while unknowingly inheriting assumptions from the second.
The widespread adoption of the BPS theory in medical schools, particularly in 1990s UK, was generally confused with the common-sense interpretation. Yet, this was complicated by the mixing of the psychosomatic model like a very bad cocktail. This has left a generation of doctors with fundamental conceptual confusion. And this still has a detrimental impact on patients.
Why has it spread rapidly? Because it offers a middle ground between biomedical reductionism and psychoanalysis, while giving clinicians a practical language for discussing complex illnesses.
Devastating Consequences
It is important to note that this is not just theory—there are heartbreaking ethical and practical stakes. We see this in BPS clinics that are usually some Frankenstein’s monster of the two interpretations. And we have a disciplinary creep or psychiatric imperialism where psychiatry claims illnesses it does not have primary authority over.
Like the adoption of hysteria, it has led to:
research stagnation, as there is an explanatory model acting as a cuckoo
psychiatric misattribution and psychiatric and psychological clinical involvement.
internalised doubt in patients
delay in effective treatment or understanding of pathology.
We have seen modern critique capture this harm and its impact. Further reading of Hunt, Roberts, O’Leary, Schomerus, Geraghty & Esmail, and Marks clearly show the consequences for patients.
Yet it is the establishment of a biopsychosocial clinical ecosystem around illnesses often designated as medically unexplained symptoms (MUS), such as ME/CFS, fibromyalgia, Long Covid and chronic pain, that has made the harm so pervasive. These are often rehabilitation-led multidisciplinary (MDT) clinics that prioritise lifestyle management and symptom management over medical investigation and disease-specific treatment. Most importantly, they have no capacity to care for those severely affected.
Solving the harm for many patients means a radical cultural and pragmatic change in the NHS where this clinical model is abandoned and replaced by specialist medical care. Non-contested diseases such as Parkinson’s are typically led by consultants and specialist nurses, with access to investigation, diagnosis and medical treatment across the spectrum of severity. Patients with ME/CFS, Long Covid and related conditions deserve the same standard of specialist medical care.
A Way Forward
In medicine, biological claims require a measurable mechanism before they are accepted. Drug intervention requires testing and evidence. Psychological models are often accepted simply because the biology is incomplete. This creates an evidential double standard.
When the biology is uncertain, psychological explanations become epistemically easier - and do not require evidence. This leads to a built-in asymmetry and a drift towards psychologisation in poorly researched and understood illnesses.
One can easily see the problem of gender, especially as researchers were encouraged to remove women from all medical research from 1977 in the US—at exactly the same time the BPS model was established and then propagated.
The problem is not that the biopsychological as proposed by Engels was malicious; it was that it was disastrously under-specified, vague, and beset with psychosomatic framing. And in medicine, under-specificity creates space for bias and maltreatment.
Medicine can respect psychological health and advocate for better social conditions without using them as a default causal hypothesis. Holistic care does not need explanatory psychologisation. This is what Hippocrates called for, as does the medical humanism of Osler. A doctor can treat the disease in the body whilst attending to the human being.
A return to these medical first principles and not the contrived choice Engels forced is a way forward. The irony is that a model that was meant to expand medicine has curtailed biological investigation. It is such a conceptually murky and messy area that there is a strong argument to be made that the term should be retired.
A way forward is for medicine to have the conceptual fortitude to correct its misunderstanding. This will lead to prioritising evidence-based biomedicine, filling the research funding gap, transparency about uncertainty and informed, supportive mental health care for patients without concern that it will be assumed to be a causal factor in their disease.
Note: We are just about to break for our annual August break, so things will be quieter from us over the next month. Yet, we wanted to say a heartfelt thank you to all our readers, friends, and all those affected by Long Covid & ME. Having you alongside means the world. We also already have plans for next year, including continuing our 101 series and an enhanced website. Remember rest is radical!
VISUAL SUMMARY
101: 03. THE BIOPSYCHOSOCIAL MODEL
Infographic Published: 29/07/26
Infographic independently reviewed by 3 people with lived experience.
Related content: 101: 01. On Psychologisation
Comments