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Historical Development of the Biopsychosocial Model in Relation to School Psychology

University of Calgary
Carli Newberry


Historical Development of the Biopsychosocial Model in Relation to School Psychology
Over the past several millennia, humans have been on the pursuit of
understanding themselves biologically, psychologically, and as social beings. In each of
these three strains, intellectual giants have left behind their legacy of ideas and research
for future generations to expand upon. The view from atop these giants shoulders has
revealed the interconnectedness across disciplines, and has increased the complexity of
understanding human beings exponentially. We are currently in a very privileged time in
academia where any research publication worldwide is just a mouse-click away, and the
entirety of global knowledge can be stored on a handheld device and kept in our pockets.
It is also a very intimidating time in the world of psychological theorists, as they are
dealing with the daunting challenge of synthesizing multi-disciplinary research to create
an accurate and holistic lens through which to view humankind. One resultant theory of
this process is the biopsychosocial model, which incorporates physical and mental health
as well as greater social well-being. While this theory was coined only 60 years ago, it
has been intuitively understood and present in practice for thousands of years. This paper
will examine the historical evolution of this theory, its current relevance in psychology,
and the implications it carries for school psychologists.
The Biopsychosocial Theory
The World Health Organization has maintained the same definition of health
since 1948, stating, Health is a state of complete physical, mental and social well-being;
and not merely the absence of disease or infirmity (WHO, 1948). This definition was
precocious when it originated as during the time it was written, the most widely accepted
medical theory was the biomedical method, which is a theory based exclusively on the

biological component of an individuals well-being. In fact, the biomedical model is still
prominent today as the health care system is in the midst of a paradigm shift towards the
biopsychosocial perspective (Frankel, Quill & McDaniel, 2003).
The biopsychosocial model is a shift towards a more ideal paradigm (Asokan
2009). It encompasses biology, as the cause of an illness may stem from a function of the
body; psychology, as the cause of health problems may be based in a more psychological
etiology such as poor self control, emotional turmoil or negativity; and sociology as the
cause of an issue may be based in socioeconomic status, culture, poverty, technology or
religion (Asokan, 2009). This model concisely incorporates the previously stated World
Health Organizations definition of health as it considers mental, social and physical
In 1977, George Engel, a physician, coined the term biopsychosocial, as he
claimed that all three levels of people, the biological, psychological and sociological must
be considered during every health care task (Engel, 1978). He elaborated that the
biological components of disease should not be considered the zenith of a diagnosis. He
further explains with a hypothetical example comparing two men with the same
biological condition (e.g., diabetes), however, only one of the men consider themselves
sick, while the other man considers his symptoms problems of living (Engall, 1977).
This, Engal felt, was evidence for considering the role that individual ideals (psychology)
and support systems (sociology) play in comprising an illness.
When considering all three components, the biopsychosocial model may be
considered a hierarchical continuum comprised of more complex, larger units super-
ordinate to less complex, smaller units. For instance, a family is super-ordinate to a

person, and an organ is superordinate to a cell, and so on (Frankel, Quill & McDaniel,
2003). Engel (1980) clarifies that it would be inappropriate to compare a familial
relationship to a cellular relationship within the same person. Moreover, he states that
there are two hierarchies, and that an individual can be both at the top of the organismic
hierarchy, and at the bottom of the social hierarchy.
Finally, the biopsychosocial theory acknowledges that each of the three
perspectives can influence one another. For example, psychological and sociological
experiences are recognized in the brain as memories or learning. Forming new memories
is dependent upon revision of the current neuronal structure of the brain. (Garland &
Howard, 2009). Therefore, psychology and sociology are inextricably linked to biology
via the neuroplasticity of the central nervous system.
Historical Development of the Biopsychosocial Model
The idea that biology, psychology and sociology are interconnected
synergistically is hardly a new one. It can be traced back to the 14
century BCE in
China during the Shang Dynasty, although the earliest written record of this model is in
the 1
century BCE in a text named Huangdi Neijng, or more common in the Western
world, The Yellow Emperors Inner Cannon. These ancient teachings examined
etiologies of disease and determined they could be biological (e.g. raw food, alcohol,
parasites), psychological (e.g,. fear, sorrow, anger), or social (e.g. traumatic events)
(Veith, 1972).
Similar to the beliefs of the ancient Chinese, the ancient Indians practiced a
medicine called Ayurveda during the same era. Ayurveda stresses a balance of three
elemental substances, and claims that this natural system should be balanced by

structuring and individuals behavior and environment to provide the individual with the
elements they are lacking (Ayurveda, 2012). Interestingly, this ancient model of
healthcare is endorsed by the World Health Organization as a viable alternative medicine.
The WHO acknowledges that Ayurveda can help to protect and improve citizens health
and well-being (WHO, 2010).
Over three centuries in ancient Greece, from approximately 500BCE 300 BCE,
upwards of nineteen physicians associated with Hippocrates collaborated to pen the
Hippocratic Corpus, a collection of medical knowledge (Tuke, 1911). These works
ultimately rejected divine causality and promoted the idea of determinism, the idea that
every symptom has a determinate cause (Adams, 1891). The most well-known example
of this paradigm shift in thinking was when Hippocrates deemed epilepsy, a disease
previously thought to be sacred or divine, as having physiological origins (Alexander,
1962). This deterministic, cause and effect way of thinking, taken alone, laid the
groundwork for the biomedical model of medicine, thus initiating a pendulum swing
from divine causality to biological etiology.
However, the Hippocratic Corpus is also credited with promoting the concept of
humourism (Adams, 1891). Humourism parallels the theory that bodies contain a
balance of earthly elements (fire, water, earth, air), but is slightly more biologically based
as the humours are a tangible bodily fluids. Blood, yellow bile, black bile, and phlegm, it
was believed, would wax and wane in the body, and an imbalance of the four humours
would cause an illness. Treatment for these types of illnesses were largely environmental
and included such recommendations as changing diet, occupation or to move to a
different geographical region (Kiersey, 1998). The theory of humourism can be likened to

the Ayurvedian theory of the balance of three elemental substances, which also promote
similar environmentally based treatments. Taken together, a deterministic approach to
humourism better supports the current theory of the biopsychosocial model than the
biomedical model, as it considers biological components through an environmental lens.
During this same time, there were also significant advancements exclusive to the
field of psychology. In the 4
and 3
centuries BCE, the philosopher Socrates introduced
the idea that the solutions to ones problems were within the self, encouraging people to
move away from divine causation. Shortly afterward, his student, Plato, proposed that the
mind and body are distinctly separate. He believed this so ardently that he deemed all
sensory organs to be a hindrance to the acquisition of knowledge. Furthermore, he
believed that after death, the mind, or soul, goes on to access the universal truth
(Silverman, 2008). Contrary to Platos beliefs, Aristotle claimed that the soul is a
property of a body, much like colour is a property of an apple (Sachs, 2001). What these
philosophies all have in common is that they detract from the divine and purport that a
greater understanding of the self, comes from the further examination of the self. These
revelations allowed for psychology to remain consistent with current medical beliefs.
Over the next few centuries, Greek physicians continued this trajectory of medical
advancement. Two noteworthy individuals were Herophilus and Erasistratus, who raised
the level of anatomical knowledge of the human body to a level that was unparalleled
until the mid-16
century (Faulkner, 2013). They were followed by Galen in 1
CE who built upon their new biological knowledge, the humourism model proposed by
the Hippocratic Canon, and current philosophical ideals. He expanded upon humourism
to include more of a psychological perspective by associating personality and emotions

with each humour, as he fervently propagated that the best physician is also a
philosopher (Brian, 1979). Galen maintained a keen interest on the debate between
rationalist and empiricist medical sects, although his more holistic perspective, which
was similar to todays biopsychosocial model, allowed him maintain a compromising
approach between these two extremes (Brian, 1979).
From the commencement of Christianity to about halfway through the second
millennium, medical advancements ceased in most of Europe. Many of the medical
centres built during the Roman Empire had been disassembled, and the Catholic belief at
the time was that it would be easier for the sick to get into heaven, decreasing the
inclination to seek medical attention. Furthermore, in the desperation created by the
chaotic political environment, people turned back to divine causation, superstition and
folk medicine (Porter, 1997). Out of the Christian hiatus in academia rose the Islamic
Golden Age. Undistracted by the politics and social pressures of developing a new
religion, the Muslim scholars continued to build upon the knowledge of the Greeks, and it
is argued that it was the Islamic scholars; rather than the Europeans, who founded
Western medicine (Pormann, Savage-Smith & Hehmeyer, 2007).
Muhammad ibn Zakariya Razi was a prominent physician and philosopher during
the 8
and 9
centuries. Razi separated the science of the psychic into the physical and
spiritual. He asserted that it was pertinent that a doctor must master both the physical and
the spiritual aspects of humanity if they are to be truly effective. So respected was his
perspective on medicine, that the text he penned in the 9
century, Comprehensive Book
of Medicine, was used until the mid 17
century as the main source of information in

medical schools (Karaman, 2011). His multi-faceted consideration of patients well-
being is a model that is revered over a millennium later.
Abu Zayd Ahmed ibn Sahl Balkhi, a Muslim psychologist practicing at the same
time, held similar beliefs to Razi. Balkhi outwardly criticized physicians at the time for
placing too much emphasis on the physical symptoms of a patient, and not enough on the
spiritual and psychological experiences of the individual (Deuraseb & Talib, 2005). As
the current medical world attempts to shift towards a biopsychosocial perspective, his
argument remains as valid today as it did one thousand years ago. He elaborated that the
body and soul cannot exist without one another, and they share an interdependent
relationship. He illustrates this point by explaining that a grave physical illness can
deplete the soul, leaving a patient feeling morose and devoid of the joy he used to find in
his preferences (Deruaseh & Talib, 2005). Furthermore, it is Balkhi who is believed to
have pioneered cognitive therapy. Throughout his practice, he differentiated three types
of depression: regular sadness, endogenous depression which originates from within the
body, and reactive clinical depression which originates from external factors (Haque,
2004). The origins of these types of depressions indicate the factors that Balkhi found
significant: psychological (regular sadness), social (reactive clinical) and biological
(endogenous). Finally, Balkhi maintained that the balance between body and mind was a
requirement of good health (Haque, 2004) which is commensurate with the current World
Health Organizations definition of health.
The 16
to 18
centuries found Europe in a period of scientific revolution. In the
century, Rene Descartes, a renowned French philosopher, incorporated biology into
his theory of dualism, claiming that the mind and body are separate entities which

connect in the pineal gland, and influence each other in a bidirectional manner
(Desmond, 2006). Descartes was supportive of a more holistic view of health, and he was
essentially reiterating thousands of years of consensus before him. Nevertheless, during
this era as more was discovered about biology, physics and chemistry, a concerted effort
was put forth in the scientific community to de-animate science. Psychology was a
field that was too reminiscent of superstition and divine causation, and too far removed
from tangible science. As a result, over the next few centuries most progress in the field
of psychology was retarded (Alexander, 1962), although it did not disappear entirely.
Sigmund Freud is infamous for popularizing (and sensationalizing) modern day
psychology. Unfortunately, Freud was very singular in his psychological beliefs, and did
not consider biology in his theories. So removed was Freud from the biology of the
central nervous system, that he claimed that hysterical conversion, or somatization, is the
result of a mysterious leap from psychic to physiologic (Fred, 1920). His student,
Franz Alexander, however, did not understand Freuds lapse in understanding, and
described this phenomenon as no more mysterious than motor nerve enervation
(Alexander, 1943).
Mere decades later, George Engal published his seminal paper on the
biopsychosocial model of medicine, urging practitioners to adopt a more complete,
holistic perspective on health (1978). Since its publication some criticism has arisen, the
most vocal of which, is Niall McLaren (1998). McLaren sardonically writes,
Since the collapse of the 19th century models (psychoanalysis, biologism and
behaviourism), psychiatrists have been in search of a model that integrates the
psyche and the soma. So keen has been their search that they embraced the so-

called 'biopsychosocial model' without ever bothering to check its details. If, at any
time over the last three decades, they had done so, they would have found it had
none. This would have forced them into the embarrassing position of having to
acknowledge that modern psychiatry is operating in a theoretical vacuum.

Interestingly, McLaren is implying that psychoanalysis, biologism and behaviourism
were more securely founded in research than the biopsychosocial model. These three
theories collapsed because they alone were not encompassing enough to explain all
aspects of humanity, which does not make them inaccurate, it merely renders them only
partial truths. The biopsychosocial model can be understood as the combination of these
three theories to create a synergistic, holistic new theory. Furthermore, McLaren (1998)
went on to acknowledge that psychology, biology and sociology are all factors in mental
illness, yet still believed naming a model biopsychosocial was a nominal fallacy.
Current Research Based on the Biopsychosocial Model
Neurosequential Development
In Bruce Perry et. al.s (1995) seminal text, When States Become Traits, neural
development is described in children who have undergone severe trauma in terms of a
biopsychosocial perspective. When children are exposed to trauma (a social stressor),
they experience a variety of adaptive mental (psychological) and physical (biological)
responses. Two elaborated on in this article are dissociation and physiological
hyperarousal. The more often the child experiences a state of dissociation or
hyperarousal, the more organized and internalized these neural pathways become. During
critical and sensitive developmental periods in childhood, these reactive states of being

can develop into personality traits. As these children age, they exhibit clinical symptoms
that are very difficult to treat if their etiology is not understood.
Attention Deficit Hyperactivity Disorder (ADHD)
In his thought-provoking book on ADHD, Scattered, Gabor Mate (1999)
proposes a novel perspective on the etiology of ADHD Inattentive Type (ADHD-I), as
he claims it is environmentally caused. Similar to Perrys explanation of how states
become traits, Mate proposes that when early infant caretakers are not attuned to the
needs of their baby, the infant finds itself in distressing situations (e.g. wet diapers,
hungry, cold). As infants have very few ways to cope with stressors, one of the few
coping mechanisms they have is to dissociate. Mate explains that infants who are
frequently placed in situations where their only escape is dissociation will develop
dissociative states. These childrens strongest neural pathways will be to disconnect from
reality and go into their own world, consequently, they will have a very difficult time
sustaining attention. Mate goes on to explain that ADHD-I appears to be genetic as it
certainly follows familial lines, however, he argues that it is not the expression of a gene
that is causing the ADHD-I in the next generation; rather, it is the cyclical pattern of
childrearing practices found in families. The individual with ADHD-I will be,
understandably, unattuned to their child as they are inattentive by nature, perpetuating the
John Bowlby proposed his theory of Attachment (1977) after a career of
providing psychiatric care to orphaned children from World War II. Bowlby recognized
that it is essential that infants form a secure bond, or attachment, with a primary

caregiver. He elaborates that the quality of this early relationship will predict the
individuals ability to form, keep, and enjoy any future relationships. Furthermore, he
noted the repercussions of not forming secure attachments may present as clinical and
anti-social behaviours.
Epigenetics focuses on how environmental influences can create cellular changes
in humans. Following a strictly biological model, a parents environmental changes
should not influence their offspring at all. However, it has been demonstrated that these
environmental changes in individuals are being genetically passed on to offspring
(Holliday, 2006) involving a very close, very powerful tridirectional relationship between
biology, sociology, and psychology. Epigenetics have been linked to the passing on of
heart disease within certain ethnic populations (Ordovs, J. M., & Smith, C. E. 2010),
psychiatric disorders (Abdolmaleky, Thiagalingam & Wilcox, 2005), and type II diabetes
(Ling & Groop, 2009) among many others. It is even suspected to have a role in autism
(Schanen, 2006).
Implications For Future Research in School Psychology
The biopsychosocial model both complicates and improves the validity of future
research in school psychology. It is well accepted now, that children do not operate or
function singularly. They rely on several levels of social structuring, are subject to
innumerable genetic predispositions, and can exhibit an inexhaustive list of psychological
properties. It is necessary to consider all three components of children when researching
to attain valid and reliable conclusions. Because the aforementioned research has already
made significant findings utilizing the biopsychosocial perspective, it is necessary that

children continue to be considered in research through a holistic, biopsychosocial lens.
This may result in an increase in experimental costs, as studies will inevitably become
longer projects that need to consider many more factors than in the past. Similarly, there
may be a decrease in the volume of research on children and humans in general, as again,
each study will be more intensive and time consuming as all relevant factors must be
considered. Most noticeably will be the integration of medical disciplines with school
psychology. School psychologists will need to become versed in relevant medical
research procedures, as well as any relevant medical jargon if they wish to remain current
in the field.
Implications for School Psychologists in the Field
A thorough understanding of the biopsychosocial model, or at the least, an
appreciation for how social, psychological and biological factors are involved in
psychopathologies, will likely become the new precedent for practicing school
psychologists. It is in fully understanding the etiology of a psychopathology that it can be
treated. For instance, when working with a child who has undergone severe trauma, who
when threatened, lashes out, it would be unethical to recommend behavior modification
therapy when their behaviours can better be understood at a neural level using the
biopsychosocial perspective.
Furthermore, full utilization of this model of thinking will lend itself to early,
involved interventions. For example, Dodge and Pettit (2003) examined conduct
disorders from a biopsychosocial perspective, and recommended that all kindergarten
aged children residing in violent neighbourhoods be screened for early conduct issues.

Those identified would then receive family and community based interventions to shift
their behavioural development to a more positive, societally appropriate trajectory.
Another proactive approach a school psychologist could take is to provide early
parenting education. These sessions could focus on developing positive, secure
attachments between caretakers and infants, and support parents in becoming attune to
their infants needs. While this seems like it is out of the realm of the school entirely, the
current evidence linking early childcare with clinical behavioural issues is too salient to
Finally, practicing school psychologists should endeavour to collaborate on multi-
disciplinary teams so that each aspect of their students can be considered accurately and
validly. This would help to ensure that all aspects of a child are being considered, and to
lesson the responsibility of one person to understand every aspect of a child biologically,
socially and psychologically, as this is unrealistic and impractical.
The biopsychosocial perspective allows a school psychologist to consider the
child as a whole, and how they interact with the many hierarchical levels within their
environments. While the biopsychosocial model has been recently coined, the essence of
the model has been acknowledged for millennia. It has always been intuitive for people to
consider others in the light of multiple perspectives, but the relatively recent period that
valued hard sciences devalued these intuitive feelings, effectively eliminating social
and psychological considerations from general healthcare. Current technology has
progressed to a point that we can now observe biological reactions as the result of feeling
an emotion such as fear or love, or from engaging in social behaviours. Consequently,

psychology and sociology are being regarded as more valid aspects of a person, and as a
result, research is incorporating a broader, more realistic scope of factors to reflect these
new biopsychosocial beliefs.
For the school psychologists, this greatly expands the breadth of information for
which to be responsible, it encourages multi-disciplinary collaboration, and it promotes
the need for early, proactive interventions.
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