The Biopsychosocial Model:

Exploring Six Impossible Things

RONALD M. EPSTEIN, MD
FRANCESC BORRELL-CARRIO, MD
In our view, the biopsychosocial model is a
vision and an approach to practice rather
than an empirically veriable theory, a co-
herent philosophy, or a clinical method. In
some cases, when that vision is confused
with ideologic dogmatism, it can invite
abandonment of the vision entirely or in
selected situations. The authors suggest
that habits of mind may be the missing link
between a biopsychosocial intent and clini-
cal reality. These habits of mind include
attentiveness, peripheral vision, curiosity,
and informed exibility. These qualities are
teachable and can be reinforced. Rather
than aspiring to being biopsychosocial
some imagined, static statecommitment
to an ongoing process of becoming biopsy-
chosocial is more pragmatic and realistic.
Keywords: physician-patient relations, clini-
cal practice, theory, philosophy of medi-
cine, history of medicine
Alice laughed: Theres no use trying,
She said; one cant believe impossible
things.
I daresay you havent had much prac-
tice, said the Queen. When I was
younger, I always did it for half an hour
a day. Why, sometimes Ive believed as
many as six impossible things before
breakfast.Lewis Carroll, Alice in
Wonderland
We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the rst time.
T. S. Eliot, Little Gidding, Four
Quartets
S
ince the early descriptions of the bio-
psychosocial model, practicing clini-
cians have had difculty reconciling the
biopsychosocial model with clinical reality
(Borrell-Carrio, Suchman, & Epstein,
2004; Frankel, Quill, & McDaniel, 2003).
As family physicians, we experience those
difculties rst hand. We believe that
these difculties are rooted in confusion
about whether the biopsychosocial model is
(a) a theory and therefore empirically ver-
iable, (b) a philosophy and therefore logi-
cally consistent, (c) a descriptive model to
expand the scope of clinical inquiry, (d) a
Ronald M. Epstein, MD, Rochester Center to Im-
prove Communication in Health Care; Francesc Bor-
rell-Carrio, MD, University of Barcelona and the Pri-
mary Care Center La Gavarra, Cornella de Llobregat,
Spain.
Conceptualizations were by Drs. Epstein and Bor-
rell-Carrio. The article was written by Dr. Epstein
and revised and approved by Dr. Borrell-Carrio.
We thank Ted Brown, PhD, for his careful reading
and historical information.
Correspondence concerning this article should be
addressed to Ronald M. Epstein, MD, Professor of
Family Medicine and Psychiatry, Rochester Center to
Improve Communication in Health Care, 1381 South
Avenue, Rochester, New York 14620. E-mail:
ronald_epstein@urmc.rochester.edu
Families, Systems, & Health Copyright 2005 by the Educational Publishing Foundation
2005, Vol. 23, No. 4, 426431 1091-7527/05/$12.00 DOI: 10.1037/1091-7527.23.4.426
426
belief system and therefore not subject to
empirical proof, (e) a guide to practice and
therefore with an implicit or explicit meth-
odology, and/or (f) a vision of a way of prac-
tice. We nd difculties in all six of these
domains. In this article, we explore all six
of these domains and the implications of
applying a split model, as Herman (1989)
suggested. We also propose that habits of
mind may be the missing link between a
biopsychosocial intent and clinical reality.
In addition, we will argue that linear ap-
proximationcircumscribed reduction-
ismis often necessary to reafrm the
model itself.
As a theory, the biopsychosocial ap-
proach includes a hierarchy of natural sys-
tems and emphasis on the fact that subjec-
tive experience is amenable to scientic in-
quiry. But, the hierarchy of natural
systems is an incomplete model; in some
cases, it might not be a hierarchy, and not
all levels are weighted equally in all situa-
tions. Rather, the elements may be ar-
ranged in different ways depending on the
problem encountered. Consider the exam-
ple of an adolescent with a sore throat. The
relevant elements in one particular patient
might include the cellular level (the bacte-
rium or virus), the molecular level (the re-
sulting inammation), and the social level
(having to miss school), whereas the organ
system level and dyadic levels might not be
as relevant for him or her at this time. A
diagram of this interaction and the relative
importance of each element would look
more like a matrix or a web rather than a
linear ordering of levels. If the theory of a
biopsychosocial approach rests on verica-
tion of a linear hierarchical model, we will
not nd convincing evidence that that
model applies to all situations. Rather, the
model should perhaps consist of matrices
dened in part by who the patient is and in
which situation he or she encounters him-
self or herselfsensitivity to initial condi-
tions in complexity theory (Plsek, 2001).
Complex models may be difcult to justify
without some degree of unquestioning be-
lief in their truth.
One of the difculties with philosophical
movements is that adherents have a differ-
ent set of experiences that led them to their
espoused beliefs than the founders did. En-
gel was rst a scientist, initially interested
in reductionistic applications of laboratory
concepts and methods but increasingly in-
trigued by direct observation and clinical
phenomenology. Through a set of personal
realizations, the scope of his scientic in-
quiry expanded to include application of
the insights of psychoanalysis and atten-
tiveness to the subjective dimensions of hu-
man experience and interpersonal relation-
ships (Brown, 2003). In his clinical role, he
was, however, rarely limited by time. His
well-deserved fame as a teacher came from
his extraordinary capacity to observe as-
tutely, be curious, and see the world
through the patients eyes. He created an
approach based on those observations, but
it was a descriptive approach based on an
evolved clinical interview and his skill in
narrative storytelling. The logical consis-
tency of a biopsychosocial approach is inti-
mately tied up with who George Engel was
as a person and his personal mission to
establish scientic rigor in the eld of sub-
jective human experience of health.
Engels biopsychosocial model was a de-
scriptive model to understand patients ill-
ness experiences and, in that way, assist
and expand the diagnostic process. Even as
his career evolved, he was only secondarily
interested in treatment. His classic devel-
opmental study of Monica is a case in point;
it was about experiment, observation, pre-
diction, and description and much less
about treatment, even though Engel and
his team were deeply committed to Monica
and invested in her successful development
(Brown, 2003). Engels descriptions may
not be quite complete enough to guide
treatment.
Considered as a belief system, the bio-
psychosocial model provided an important
corrective action to na ve psychosomatic
SPECIAL ISSUE: BIOPSYCHOSOCIAL MODEL: SIX IMPOSSIBLE THINGS 427
approaches whose proponents proposed
that unconscious conicts or life stress op-
erated through simple mechanisms to
cause physical illness. For others, however,
biopsychosocial has a narrower connota-
tion of nding psychological causes for
physical illness, which ignores the more
complex interactions that Engel empha-
sized. Engels writings invite clinicians to
see illness in a broader context that in-
cludes but is not restricted to human sub-
jective experience and to use all of their
human capacities and clinical skills to un-
derstand the way that subjective experi-
ence is important in each clinical situation.
As a guide to practice, Engel and his
students and followers have developed clin-
ical methods for communicating with pa-
tients and engaging in clinical reasoning.
However, the biopsychosocial approach
sometimes is misunderstood to imply that
specic behaviors, such as using empathic
comments, being nice, or offering choices,
are biopsychosocial. But, of course, empa-
thy is meaningful only if used appropri-
ately; empathy can be misplaced and thus
seem false. Being nice, depending on the
context, may not always be appropriate;
one can simultaneously be nice, paternal-
istic, and rigidly biomedical. Offering
choices in an attempt to be empowering can
also be misapplied; for example, patients
with severe pain may require analgesia be-
fore a meaningful relationship can be es-
tablished and choices can be considered.
Thus, it is difcult to specify particular be-
haviors that are intrinsically biopsychoso-
cial. Context and practical wisdom can
guide the clinician in discerning which
level of the spectrum is relevant for which
problems and which responses might be
meaningful to the patient. This takes prac-
tice, critique, and mentorship.
In our view, the most important contri-
bution that Engel has given us is a vision
that in health and illness, there is more
than meets the untrained eye. He empha-
sized over and over that subjective human
experience is and should be a focus of sci-
entic study, alongside and in equal impor-
tance with reductionistic, mechanistic. and
physical explanations of illness and suffer-
ing. The timing of his 1977 article (Engel,
1977) coincided with a resurgent medical
reductionism that was largely unopposed,
and, in particular, was effecting a radical
revision of psychiatry (Eisenberg, 1986). A
new vision was needed to maintain, or re-
constitute, a medical practice that could
adequately address suffering. But to apply
this vision, clinicians need practical wis-
dom for guidance; knowledge and tech-
niques are not sufcient (Davis, 1997).
There is a danger, however. Even holistic
visions can paradoxically degenerate into
rigid orthodoxy that limits the ability of
adherents to make and validate new obser-
vations and to apply new therapeutic
strategies.
Linear approximations are often neces-
sary to understand complex recursive sys-
tems. One does not consider the theory of
relativity when applying the brakes while
driving. This is not only because attending
to every level in every moment with every
patient is bound to be overwhelming but
also because linear approximations create
frameworks that can inform a holistic view.
The solution is not creating a narrower vi-
sion. Rather, it is starting, as Engel em-
phasizes, with the patients story. Patients
experiences and accounts of illness are gen-
erally not partitioned into biomedical and
psychosocial domains; even the words bio-
medical and psychosocial are not particu-
larly meaningful from the perspective of a
suffering person. Starting from an under-
standing of this unpartioned overall expe-
rience, the clinician can then develop a
method for taking those pieces of the whole
that are relevant for each case. Often the
patient will tell the clinician which ele-
ments those are, sometimes they will form
a recognizable pattern based on prior expe-
rience (Schmidt, Norman, & Boshuizen,
1990 ), and sometimes the review of sys-
tems and mechanistic explanations may be
helpful to survey of the terrain as long as
428 EPSTEIN AND BORRELL-CARRIO
the clinician does not consider them synon-
ymous with the entire clinical method.
Starting with simplied models, the clini-
cian can then expand these to view the
whole situation in perspective.
What practical lessons are we to gain
from Engels wisdom? The rst is that,
whatever the focus of the patients prob-
lem, the clinician must adopt two types of
visionrst, a direct vision of the problem
unencumbered by categories, and second, a
peripheral vision that can x on relevant
data at the edges of the principal focus.
Creating categories, if taken too seri-
ously (e.g., the pancreatitis in room 403,
the somatizer), limits the clinicians vi-
sion. But, without categories, we are lost at
sea and are diagnostically inept. One ap-
proach to this conundrum is to adopt frag-
ile categories, as William James suggested
(James, 1975), in situations of clinical am-
biguitynot taking our formulations as
fact but rather as a way of structuring am-
biguity and cultivating the ability to main-
tain more than one perspective at the same
time.
Peripheral vision can take in various
types of data for which the ones mind is
preparedsocial data, psychological data,
biomedical data, and laboratory data. But,
some things are invisible to the unprepared
mind. Preparation should include knowl-
edge and experience and also adopting the
curiosity that Engel exemplied in his in-
teractions with patients; this curiosity
should pervade the clinicians broad under-
standing of the situation. Other fundamen-
tal qualities are attentive observation and
informed exibility. These qualities are
teachable and can be reinforced.
Second, there is a pressing need to re-
ne teaching in medical school and resi-
dency to emphasize not only clinical skills
but also attitudes of mind, such as aware-
ness of context and being-in-relation with
the patient (Zoppi & Epstein, 2002). Train-
ees should learn how, for example, a facil-
itating comment in one context might be an
interruption in another (Makoul, Rinta-
maki, Epstein, Marvel, & Frankel, 1999;
Marvel, Epstein, Flowers, & Beckman,
1999). Biopsychosocial training requires
face-to-face human contact involving direct
observation and critique by master clini-
cians in the context of an apprenticeship or
mentor-mentee relationshiprarities in
current medical training (Ludmerer, 1999).
Teachers need methods that are transpar-
ent and pragmatic enough to reach stu-
dents whose interpersonal skills are not
necessarily well-developed on entry to
medical school and adaptable to a variety
of clinical settings. Student assessment
programs set standards for clinician behav-
ior; these should effectively identify and
reward informed exibility, not just the
completion of checklists (Epstein, in press).
Fortunately, there has been progress
since Hermans article 16 years ago.
Courses in communication with patients
are nearly universal in medical schools. In
Rochester, we have developed exercises for
students and residents in communicating
evidence for informed decision making (Ep-
stein, Alper, & Quill, 2004), building rela-
tionships with families in busy primary
care settings (McDaniel, Campbell, Hep-
worth, & Lorenz, 2005), engaging in clini-
cal reasoning that incorporates the pa-
tients elicited values, and using reective
questions to foster self-awareness and limit
the likelihood of misunderstandings and
errors (Borrell-Carrio & Epstein, 2004; Ep-
stein, 2003). Collaborative work with men-
tal health professionals is more common.
Forward-looking student assessment pro-
grams are designed to make it difcult to
resolve clinical situations without synthe-
sizing a wide array of relevant databio-
medical, psychological, intersubjective,
and ethological (Epstein et al., 2004).
Practically speaking, what was lacking
in the clinical encounter described by Dr.
Herman was not that he delayed arriving
at the diagnosis, but rather that he had not
put himself in a position where he could
listen and pursue relevant data, probably
because of having made assumptions about
SPECIAL ISSUE: BIOPSYCHOSOCIAL MODEL: SIX IMPOSSIBLE THINGS 429
what he would nd. These limiting as-
sumptions were unexamined until after the
diagnosis was made. Often, the reasons for
not examining assumptions can be traced
to psychological factors in the clinician
fatigue, not wanting to face a possibility of
more work, avoidance of difcult topics,
and/or the desire for the patient to have a
condition that the physician feels comfort-
able treating (Borrell-Carrio & Epstein,
2004). In this case, perhaps the clinicians
inner dialogue included thoughts such as,
Shes complaining of fatigue like so many
other patients, and its probably a psycho-
logical condition like so many other pa-
tients . . . . Cultivating self-awareness to
examine those assumptions in an open, at-
tentive, and curious way can help the cli-
nician deconstruct categories that have be-
come rigidied and less germane to the
patients situation (Borrell-Carrio & Ep-
stein, 2004; Epstein, 2003). This capacity
for mindful in-the-moment self-monitoring
may have been what was lacking in the
case Dr. Herman describes but clearly was
awakened once the diagnosis was reached.
There are several methods for achieving
self-awareness that can be incorporated
into medical training (Borrell-Carrio & Ep-
stein, 2004; Epstein, 2003; Novack, Ep-
stein, & Paulsen, 1999; Novack, Kaplan, et
al. 1997; Novack, Suchman, Clark, Ep-
stein, Najberg, & Kaplan, 1997). This self-
awareness takes no time for the prepared
practitionerit is the marrow of daily
practice. Preparation, though, requires at-
tention, training, and calibration to de-
velop habits of mind in approaching both
novel and familiar situations (Novack,
Suchman, et al., 1997).
Mindful practice (Epstein, 1999)un-
fettered total attention, critical curiosity,
informed exibility, and presenceis best
viewed as an asymptote that we never
quite reach. It is an invitation for clinicians
to know themselves better, including prej-
udices, points of view, and blind spots. Ti-
zon (1998) describes a biopsychosocial ap-
proach to care as an impossible humanis-
tic vision rather than an expectation that
clinicians explore each level of the biopsy-
chosocial hierarchy in each moment of each
encounter. Rather than aspiring to being
biopsychosocialsome imagined, static
statethe ongoing process of becoming
biopsychosocial develops mental supple-
ness, diagnostic agility, thoughtful ap-
proaches to therapeutics, and a holistic vi-
sion; it provides a focus for nding meaning
in clinical practice and pathways to strong
relationships with patients.
The dynamic tension exhibited in Her-
mans article should not be dismissed glibly
nor invite despair. Rather, it is an invita-
tion to learn from unexpected (and not nec-
essarily pleasant) moments of awareness.
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