The Biopsychosocial Approach: Past, Present, Future

It is certainly remarkable that we still need to be reminded of the most basic, commonsense perspective that informs both the art and science of the practice of clinical medicine. Even Hippocrates understood the importance of approaching the patient in his or her social context and treating the whole person, and early in the last century Adolf Meyer was teaching a psychosocial approach to psychiatry. Our growing sophistication as trained physicians in identifying biological underpinnings of diseases should not supplant our understanding of this approach, yet in an atmosphere of more knowledge and more paperwork and less time and less continuity of care with patients, it seems we need reorientation to what our full field of vision and practice should be.

This volume celebrates the biopsychosocial approach, so aptly named and so inspiringly taught by Dr. George Engel of Rochester, N.Y. Sadly, Dr. Engel passed away in 1999, while this book was still in preparation. The relevance of his antidote to biomedical reductionism has not diminished since its introduction many decades ago. Dr. Engel teamed with Dr. John Romano, Chair of the Department of Psychiatry at University of Rochester School of Medicine, to revolutionize the medical educational culture there, and their seminal influence in that city continues to this day. Therefore, it is not surprising that 60% of the chapter authors in this volume are affiliated with the University of Rochester School of Medicine or the University of Rochester.

The biopsychosocial approach formally saw the light of day in print in Dr. Engel’s landmark 1977 Science paper (1) (reproduced in this volume), but he is more remembered in psychiatry for his 1979 APA Vestermark Award lecture, which was published in the American Journal of Psychiatry in 1980 (2). In the latter, Dr. Engel used the example of a man experiencing a myocardial infarction and suffering cardiac arrest during his medical workup. Seeing this classic reprinted as this book’s first chapter is a delight. The following chapter by the three editors, introducing the remaining chapters, delivers some unintended irony, as the three authors misremember just-presented details of that famous vignette. (For the record, the patient endured repeated unsuccessful attempts by several house officers trying to perform an arterial puncture, not start an intravenous line; and the patient said that he consequently anticipated further painful fumbling attempts and felt outrage, then self-blame and impotence, not fear of being alone and abandoned.)

“Clinical Practice and the Biopsychosocial Approach” is an impressive chapter seamlessly written by six authors, nicely bringing Dr. Engel’s description of biopsychosocial understanding to an up-to-date approach to therapeutic practices. Subsequent chapters address other clinical applications, research, educational and administrative perspectives, and, finally, some historical background and some brief notes on comparisons with systems theory and current patient-centered and relationship-centered approaches to health care. The book is a pleasant and interesting read for those with an interest in this area, although it is written about nonpsychiatric primary care. It certainly would be relevant in training medical students and residents, as well as for use on consultation-liaison services. This volume provides a good background but is more of a well-rounded, thoughtful collection than an ideal textbook. For didactic purposes, selected chapters would do well, including Dr. Engel’s two reprinted papers.