BPS-ing badly! How the biopsychosocial model fails pain patients (Member Post)

1977: BPS is born

American psychiatrist George Engel cooked up the “biopsychosocial” theory of illness and healing, pushing back against a medical paradigm in the middle of the 20^th Century that had become excessively technical, impersonal, and paternalistic. Too many doctors acted as if patients could be treated without knowing anything about them at all other than their test results.

George L. Engel, father of the biopsychosocial perspective.

Some doctors were always wiser than that, of course! Engel was no radical (although no doubt we could probably dig up examples of doctors who scoffed at him as if he were). He just explained, in an academic way, why medicine should climb down off its high horse a bit and take patients seriously as people rather than walking pathologies. He explained that for the first time in his classic 1977 paper.3

BPS was the original “holistic” medicine (before that term was largely co-opted and corrupted by alternative medicine). It meant nothing more (or less) than “the whole person matters.” Another good catch-all term for this is just “humanistic” medicine. The same values are also quite well-known today under the rubric of “patient-centered care.” Cormack et al.:

[Engel] argued that the biomedical model was: reductionist (i.e. complex health concerns inappropriately reduced to biochemical or pathoanatomical processes); dualist (i.e. separated body and mind); and that it “…leaves no room within its framework for the social, psychological, and behavioral dimensions of illness”. He recognized the need for a new approach, moving away from the dehumanizing biomedical model as it does not include the patient and their “…attributes as a person, a human being.”

…

Engel sought to broaden the scope of the clinician’s perspective to include self-reflection on one’s approach to patient assessment and treatment… He also aspired to transform the patient’s role from a passive recipient of care to an active participant in the process of recovery.

Bravo! Reading Engel decades later, it all seems to be a bit of a no-brainer, like he was obviously ahead of his time. We might quibble (endlessly) about exactly what BPS is all about and how to apply it, but good luck finding anyone who objects to the spirit of the thing these days. That would just be weird.

And yet BPS is arguably a failure.

Yet another Venn of the BPS framework of health/care; this one has a bit of my own special sauce. Most won’t mention “prejudices,” for instance — but racism and sexism are huge social factors in healthcare, especially for chronic pain patients.

How BPS fails pain patients

Obviously it’s not all bad news, and there are notable exceptions — occupational therapy stands out as positive example, for instance4 — but the trend is discouraging. There are serious problems. People have noticed! Many patients have learned to hate BPS (even if they don’t know the term). Consider this take from @OnlyEnnui on Twitter:

“BPS model has been fucking people with myalgic encephalomyelitis for years.”

If you’re not familiar with “myalgic encephalomyelitis,” just substitute any poorly understood or hard-to-diagnose illness that causes malaise and pain (e.g fibromyalgia, Ehlers–Danlos syndrome, post-Lyme disease syndrome, endometriosis, celiac disease, and many more). Healthcare providers, often oblivious to the great diversity of “bio” possibilities, shift the diagnostic burden onto the easier scapegoat of the “psychosocial,” and pat themselves on the back for doing it. Worse, they often do this in an insidiously gaslighting way, e.g. “You’ve stressed yourself into chronic illness, it’s self-inflicted burnout, you poor self-sabotaging thing!”5

The pseudo-diagnosis of burnout just puts a coat of BPS paint on incompetence, but it’s so common that it’s the only influence of BPS that many patients have ever seen. It’s a problem that most people with undiagnosed health problems will talk about (including me). There are whole books about this dynamic.

Or it swings the other way: oversimplification of the bio, rather than overemphasis of the psychosocial. Many patients not only still get treated too much like biological machines that have a glitch, but also in an amateurish way that leads to extreme over-diagnosis of many familiar and simplistic scapegoats for common pain problems: asymmetry, inflexibility, weakness and countless more technical and specific variations on these themes, from glutes or quads that don’t “fire” when they should to subtle spinal subluxations to bad q-angles in your knees.

Biomedicalization, fragmentation, and neuromania

There are (at least) three main ways that BPS has gone wrong in the last couple decades. Cormack et al. explain that the BPS model is “often biomedicalized, fragmented, and used in reductionist ways, thereby deviating from the original model proposed by Engel.”

1. Biomedicalization — Professionals are paying lip service to humanism and holism, but still being really rather biomedical. And if you’re biomedicalizing when you’re supposed to be BPS-ing, “U R doin’ it wrong.” The whole idea is not to be excessively or simplistically biomedical! (A moderate and nuanced biomedical approach is not just okay, it’s the goal.)
2. Fragmentation — A tendency to see patients’ complaints in terms of this or that (e.g. bio or psycho or social), instead of this and that (it’s always all of the above). Even when BPS is applied more assiduously, often only one major facet of it is emphasized, at the expense of the other.6
3. Neuromania — It all boils down to the 🧠! Reducing too many problems to “the brain” — the ultimate scapegoat for symptoms, especially in the world of persistent pain, where there’s often nothing but subjective perception to try to interpret (no objective medical signs). “Reductionism” could have gone other ways, but Cormack et al. flag this specifically as a trend in the last twenty years. It’s not that it’s wrong to consider the role of the brain, of course, but many clinicians do seem to have gone a bit overboard in this direction. I am guilty of a little neuromania myself, circa 2014–2018.7

In other words, it’s not just that providers aren’t BPS-ing right: it’s more just that they aren’t really doing care the BPS way at all. They’re really just making a few token BPS noises while carrying on mostly doing healthcare the old way, making the exact mistakes that Engel wanted to fix.

Result? “Suboptimal musculoskeletal care,” presumably — although that is not a consequence that Cormack et al. substantiate, and it’s interesting to consider the fact that we do not and cannot actually know if good BPS-style care is actually better care. It’s just too hard to standardize for useful testing. It would be like trying to do a clinical trial of charisma. Or fabulousness.

“This is why you fail” — why is BPS-ing so hard?

If the BPS perspective is so attractive and wise, why are patients still so often being treated like relatively simple machines that break down? Or psychosomatic cases?

Life is full of answers that are simple but wrong, and complex but right, and guess where most people go? (I wish I could include the classic Non Sequitur comic strip here, but… copyright.) The biomedical perspective on pain and injury is widely dumbed down to an excessively “mechanical” perspective, what I have called structuralism. That paradigm is appealing and dominant because it is oversimplified: it far easier to understand, and has much clearer clinical implications than BPS. Routinely wrong! But clear. Structuralism is “actionable.”

It also drowns out other ways of looking at health and pain. The more mired a clinician is in structuralism, the more limited their BPS perspective will be. That happens even to smart professionals, but many more clinicians get sucked into the sillier fantasies of alternative medicine: meridians! fascia! vibrations! homeopathic! quantum! And much worse. Such fairy tales are even more seductive because they are even more “magical” in their promises, and even harder to falsify. No one can tell you that you are doing fascial therapy or Reiki wrong, because there are no standards, no right way to fall short of. Convenient.

To compete with such beguiling simplicity, BPS would need an extremely clear vision of a better way to do things. But the complexity of the real problem makes that almost impossible. Cormack et al. point out that “much of Engel’s writings are vague and without a strong underlying theory” and “lack philosophical coherence.” In other words, perhaps it just never clear in th first place exactly what to do with BPS or why. Engel may not have even been all that good at it himself!

It is also important to note that the tone of Engel’s writings reflect the era his papers were written in, as well as what appears, at times, a lingering affinity to aspects of the biomedical paradigm.

Is BPS busted? Nope, it’s just hard

There’s quite a lot wrong with healthcare for people with chronic pain. It’s not just that it’s hard: the difficulties are also chronically underestimated, and so the great need for the skilful application of BPS well is also underestimated.

Rocket science is hard, but that doesn’t mean there’s anything wrong with rocket science, and I don’t think there's anything wrong with BPS itself. It’s a vision of really great healthcare; it would be weird if it was gracefully, consistently implemented across the land. It’s aspirational. Here's Engel from a paper published the year after The Big One, about “the education of health professionals”:

“The key to optimal patient care is collaboration, communication and complementarity among all branches of the health professions… To buttress collaboration, communication, and complementarity, the fourth indispensable attribute of health care professionals must be competence.”

BPS-ing well takes competence, and competence is a rare and precious commodity. “Good help is hard to find” may be one of the most justified clichés of the human condition.