BJPsych Bulletin is delighted to announce Dr Simon Williamson as the winner of the 2021 Praxis Editorial Award competition. Read his complementary blog post on his winning article: “‘Is the biopsychosocial model dead?”.

The biopsychosocial model has become a staple of modern medical education, especially in psychiatry. I’ve encountered it several times during my training, often as the seemingly canonical Venn diagram of overlapping biological, psychological, and social factors. As a new psychiatry trainee, I was taught how to apply the biopsychosocial model by means of formulation. I learned that formulation is an important component of practice, and one of the core competencies I would be expected to attain. I was surprised, therefore, to see very few formulations completed in practice. Why was the model, purported to be of great value to psychiatrists, not being used?

Clearly something with the model was amiss, though the depth of the problem wasn’t immediately apparent. I decided to assume nothing of the model’s validity, and instead ask of it some fundamental questions (is it valid, is it useful and is it used?).   

In doing so, I discovered a depth to the model far greater than the Venn diagrams would suggest. Systems theory lends an intellectual weight to the model, and grounds the biopsychosocial in a framework that is philosophically coherent. Engel didn’t mean for this to remain in the intellectual space either –he showed how it could be applied in practice, envisioning genuine holistic care by ‘systems-oriented’ physicians.

Ultimately, I found no inherent flaws with the model, only in its implementation. This was not solely attributable to time constraints, but also to a view among psychiatrists that formulation is practically irrelevant. I suspect this view underlies the rift between education and practice, concealed perhaps by a tendency to pay the model lip service.

We should consider how to change this. Addressing how the model is taught might be a start. It should be communicated that, through careful consideration of interacting biopsychosocial factors, one can begin to understand an individual’s motivations, drives and behaviours. The perception of a patient’s experience and actions can then take on real meaning. Caring for the patient is inherently more satisfying and accompanied by better decisions as to which members of the multi-disciplinary team to involve and how. Teaching the model using grounded examples, as Engel did, would help to convey the value of biopsychosocial formulations.

It is also worth considering the presence (or absence) of prompts in the clinical setting. Headings in clinic letter templates, for instance, indicate to trainees what should be considered – and what needn’t be. If formulations aren’t included, they risk being perceived as unnecessary. This could be easily prevented by adding a ‘formulation’ heading to encourage engagement with the model. Other documentation could be similarly adapted to better reflect a biopsychosocial framing – if there is sufficient impetus to do so.

I chose psychiatry with a desire to understand individuals and their lives in greater depth, as did many of my peers. The biopsychosocial model, through formulation, offers us this understanding. I’m hopeful that, as long as this desire persists, the biopsychosocial model can still be revived. Engel’s vision may come to fruition yet.

Read the 2021 Praxis Editorial Award winning article here.

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