Biology / Health / Medicine / Psychology / Science

The biopsychosocial model of mental health

When I mentioned signing up for my next degree soon, I complained to someone that it’d be time to go back to arguing about the ‘biopsychosocial’ model of mental health. They asked what exactly my problem with it is, and suggested this as a good platform. Here goes!

So the biopsychosocial model of mental health is one that suggests that there are multiple factors at work in any mental illness: the biological, the social, and the psychological. It’s a holistic view, and if you know me a little, you’d think I’d be jumping at that. I do think it’s undeniable that factors of all kinds are at work in any individual when they’re mentally ill: it’s never just a deficit of serotonin, and it’s never just a poor work environment. Other factors impact those, reinforce them and are reinforced by them. I have absolutely no arguments with that aspect of the biopsychosocial model, in fact! Taken at face value, it reminds us that these factors are all there.

However, there are definitely problems with it and this is where it really drove me bananas during my degree. For example, some people are born with a short gene for serotonin, which (to cut a long story short) can lead to serotonin deficits. Right! That’s a biological factor. Job done.

Turns out it’s more complicated than that. Many people with that gene have no issue at all. Turns out that you only have issues when you’re also abused or subjected to some other massive trauma when you’re young. If you aren’t, you remain as versatile in your response to trauma as any other person; it’s only if you have that history of abuse that the issue is triggered. Ah! It’s psychological then.

My problem, then, with the biopsychosocial model, is that it often leads to people spending waaaaaay too much time worrying about classifying where exactly something falls in the biopsychosocial model, and it can also lead to people privileging parts of the model over others despite the fact that it is, on the surface, holistic. And this is important because if a medical professional is choosing someone’s treatment based on the biopsychosocial model and they think the biological aspect is the most important, they’ll prescribe SSRIs for someone with the short gene, viewing that as the source of all the problems. If they think the history of trauma is more important, they’ll withhold antidepressants and focus on appropriate therapy.

It’s fine, to my mind, as a reminder of all the different factors that inform mental illness. It does not go far enough, though. I am convinced that the social and the psychological are not separate from the biological: the model treats them as separate-but-linked, but I think they are all symptoms of the same thing. A “psychological” (as defined under the biopsychosocial model) event changes your brain chemistry and becomes biological[, and biological therapies should thus be considered in treatment, in my view].

Needless to say, my marker did not enjoy me refusing to separate things into these categories, or disagreeing with her on her classifications when I dutifully went along and pretended to believe there is any psychology not rooted in biology. [For example, she expected me to consider the issue of someone with a short serotonin gene and a history of trauma to be an entirely psychological one, and I lost marks for stating that it was both psychological and biological. These separations simply are not useful.]

The biopsychosocial model is a tool for understanding mental health, perhaps — a way of demonstrating that a holistic model is necessary, because within the model’s limits it is easy to demonstrate that these factors are interdependent — but it shouldn’t be a box we can’t see out of. And for heaven’s sake, stop trying to convince me there is some free-floating “psychology” that does not have a physical explanation unless you can bring me data, which right now (to my knowledge) no one has.

I bet my mother, a practising psychiatrist, is gonna turn up in the comments. I’m 50/50 on whether she’ll think I’ve torn enough holes in the biopsychosocial model, despite her commitment to holistically caring for her patients (insofar as the NHS makes that possible)… Do let me know, Mum.

[Edited 06/11/2019 to slightly clarify some sentences.]

12 thoughts on “The biopsychosocial model of mental health

  1. I very much enjoy yer insights on this issue and think I get yer overall point. As genetic tests get more prevalent (I had to spit into a tube for cholesterol gene testing a couple of days ago) I think people tend to treat medical / mental health issues as having one cause or focusing on only one aspect of care. The lipidologist I saw was adamant that this test was only one tool to use (I agree). I remember in psychology classes when professors refused to really teach whatever methods they didn’t believe in at the time. I think classification is helpful but sometimes people miss things because it doesn’t fit in the proper box. I was too young for cataracts (under 40) and so no one wanted to do the surgery even though I was going blind and had related symptoms that kept ending up with me in the emergency room. The doctors wouldn’t stop focusing on my age rather then my actual eyesight. People are complicated. Science is always learning. Though I have to admit that I wouldn’t be comfortable having to diagnosis or treat anymore. People like yer mom be heros!
    x The Captain

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  2. As you know I am not too keen on the BioPsychoSocial Model as it is too simplistic, everything affects everything else and in the end I think it may all come down to Biology!!

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    • What else could it be down to, after all? There is no evidence that we have minds that are separate from our brains, which is what treating biological and psychological factors as distinct implies.

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      • Para.1 of your response.
        Glad to hear my understanding isn’t out of date.

        Para. 2.
        No, I have not misunderstood anything.
        I’m saying that regardless of the indisputable fact that all psychology must have a biological origin it ISN’T essential to always refer to it and that CBT bears this out. In fact it can be obfuscatory or impossible in certain circumstances to constantly refer to deeper levels of description. Wanting to understand exactly how CBT works at the level of brain function is natural scientific curiosity but the fact that we don’t currently isn’t an invalidation of the model CBT is based on and doesn’t make it poor science. There’s a strong analogy in physics between classical thermodynamics and statistical mechanics. The former is a reliable theory that doesn’t refer to the atomic nature of matter at all and is adequate for practical purposes such as designing fridges and building eletricity generator turbines. Statistical mechanics, on the other hand, starts from the assumption that bigger things are aggregates of atoms and through some really complicated arguments leads to the same conclusions as classical thermodynamics. It’s wrong to say that because we know that things are made of atoms we should never neglect statistical mechanics. In most situations it makes solving problems harder and doesn’t generate better results.

        So in this case, the use of the simple model behind CBT is perfectly adequate to the task, and refering to brain function doesn’t help. Of course it’s possible that if we do develop a better understanding of the connection to brain function it might lead to better therapies, just as it turns out that in some rare and obscure situations statistical mechanics does prove more accurate than classical thermodynamics.

        Para 3. …not the point I’m discussing, except the last sentence.

        Para 4. My point is that in some cases treating biology and psychology as one and the same is in fact detrimental to understanding and practice. One needs to use the appropriate level of description for every particular problem. Regarding mental health, there are some models/therapies where refering to brain function doesn’t in any way help. Of course there are also plenty where it does help/is essential. See above. CBT is my example, refuting the dogmatically Reductionist view.

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        • No, it definitely sounds like you’re misunderstanding what I’m saying, since I haven’t remotely said or implied that CBT is poor science. You are arguing with me about things I have not said.

          I’m not saying that therapies based on an understanding of psychology are wrong, nor that you need to know how they bring about biological changes in order to accept their efficacy, or anything like that.

          I’m saying that creating silos where issues get characterised as only “psychological” is unhelpful, and that in practice that is what happens.

          I’m also saying that creating silos where issues get characterised as only biological (under a narrow view where only genetics or detectable changes in the brain “count” as biological) is unhelpful, and in practice that also happens.

          I’m saying that doctors decide to withhold treatments for “biological” issues (like SSRIs) because they think the issue is clearly only “psychological”, instead of recognising that they are not separate-but-linked but inextricably linked.

          I’m saying that in my experience of academia, the biopsychosocial model is treated in the way I have criticised, in a way that suggests there can be “purely” psychological (or “purely” social, or “purely” biological) interpretations of a particular mental illness, and that you can and must separate them out.

          Not all these things I’m saying are a response to what you’re saying, because you’re arguing with a position I have not taken.

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          • “The point is not that psychology is pointless, but that dividing it from biology as if they are separate is.”

            You are factually wrong about what you say you are not saying, as the above quote proves. What you say in that quote is factually wrong as the case of CBT and its underlying non-biological model proves. I repeat that it is NOT always pointless to separate psychology from biology and that sometimes it is actually advantageous.

            None of the things you say you are saying is the point in dispute.

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            • It is always pointless to look at a mental illness and decide it has no biological component, and therefore dismiss “biological” interventions. It would also always be pointless to look at it and decide it has no components which psychological interventions could affect. I’m not saying that an individual therapist trained in CBT needs to be thinking about the brain chemistry — that would indeed be superfluous. I’m saying that the person in charge of an individual’s overall care needs to do so.

              So perhaps if I edit the earlier comment to make explicit what I considered to be implicit given the context:

              “The point is not that psychology is pointless, but that dividing it from biology as if they are separate and thus considering only psychological therapies for a given individual is.”

              I should add that I’m also not saying you must treat someone with an SSRI (or other medication or physical intervention), only that all these factors should be considered, even when you think the precipitating factor of the illness is psychological.

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              • The thing is, I’m autistic and therefore tend to read and understand what people actually write/say, not what they think they imply and everyone else should therefore be able to infer without difficulty.

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  3. I thought the current consensus view was that an individual’s genetics could create a greater than average susceptability to depression or anxiety, rather than pre-determining it? Hence life events are required as triggers but the frequency/severity required to cause symptoms varies across individuals.

    As for psychology as a “free-floating” thing without biological cause – your view seems to be perhaps too heavily Reductionist. Whilst psychology is emergent from certain biological systems, biological systems are emergent from chemical systems and chemical systems are emergent from physical systems. Hence one should merely study fundamental physics because it all boils down to that eventually… Well that’s a falacious argument. There are levels of description that are immensely useful scientifically which ignore more fundamental ones but don’t deny or contradict their existence. So in the case of mental illness, Cognitive Behavioural Therapy has much evidence in support of its usefulness but it is based on a psychological theory, not a biological one. It doesn’t deny the requirement for a biological substrate, it just doesn’t need to refer to it in order to be understood or applied. Of course it’s also entirely valid scientifically to try to link levels of description, thereby explaining how one emerges from the other and all the major sciences have them, though there are still many gaps.

    So if your lecturer believed that there is absolutely never any need to take biology into account in psychology I’d have to vehemently disagree but I equally disagree that it is always essential to do so, depending on what one is aiming at.

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    • On the genetics front, yes, exactly, nothing you said contradicts what I said (unless you misinterpreted my sarcastic “right! job done”). If you’d like me to pull out the data and discuss it in more detail, that would be a whole other post.

      I think you have generally misunderstood the point. I don’t disagree with the efficacy of “psychological” interventions, but I think that necessarily all of it has a biological root in changes in the brain (which may be too subtle for us to detect at this stage).

      What I’m suggesting is wrong is the impulse to treat a psychological problem as separate from the biological, for example by saying that a poor work situation is a psychological/social problem and so does not need to be treated with (for instance) an SSRI — which is a thing real actual clinicians will claim. The psychological/social problem doesn’t stand alone outside the physical brain, but causes changes within it which produce the symptoms, and that may be reduced availability of serotonin. That means supportive therapy using SSRIs can be the most appropriate thing in helping someone turn around depression even when ostensibly caused by a poor psychological or social situation. In its turn, CBT also (through changing habits of thought) causes changes in physical brain chemistry, and can bring about long-term changes in someone’s biology through the “psychological” therapy.

      The point is not that psychology is pointless, but that dividing it from biology as if they are separate is. As I said at least twice in the post, I do think a holistic approach (i.e. tackling the problem with all appropriate resources available) is necessary.

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