The past,present, and future of the biopsychosocial model: A review of The Biopsychosocial Model of Health and Disease: New philosophical and scientific developments by Derek Bolton and Grant Gillett

Health psychology is a growing field generating exciting advances in theory, research, and applications that significantly improve the lives of individuals, shape the medical profession, and inform global public policy. For over 40 years, the field has been guided by the biopsychosocial model (Engel, 1977), an interdisciplinary and multifaceted model that posits the interrelations among the biological, psychological, and socio-environmental influences on health and disease. The theoretical implications and empirical research that it has generated have been vast. In The Biopsychosocial Model of Health and Disease: New philosophical and scientific developments, Derek Bolton and Grant Gillett (2019) present a summary of four decades of scholarship. They conclude that the model has fallen short clinically, scientifically, and philosophically. Although their book is timely, well-written, thought-provoking, and designed to highlight weaknesses that could drive science and practice forward, their criticisms are not fully convincing and are open to debate. The contributions this book could make may be to challenge a new generation of scholars and scientists to demonstrate that the biopsychosocial model is more relevant than ever, especially as areas such as social genomics, psychoneuroimmunology, health disparities, and global health become more important. Despite interesting philosophical challenges presented by Bolton and Gillett, theory, research, and practice focused on health, disability, illness, and wellness should remain grounded in the biopsychosocial model.     

Stress Overload: A New Approach to the Assessment of Stress

The link between stress and health has not received strong empirical support, possibly due to problems in the stress measures used. Here, the first wholly empirical development of a new “Stress Overload Scale” is described. A pool of 150 items was formed to reflect “overload”, a common denominator in stress theories. Then, the results of five sequenced studies, conducted in heterogeneous community samples, were used to pare the item pool. Exploratory (n = 431) and confirmatory (n = 433) analyses revealed two factors (Event Load and Personal Vulnerability) corresponding to theoretical constructs; only the best factor markers were submitted to further construct validity (n = 310) and reliability tests (n = 342). The 24 strongest items were selected for the SOS, which demonstrated criterion validity in predicting who (n = 285) would become sick following a common stressor. The SOS is (1) psychometrically strong, especially in its validity relative to popular measures; (2) appropriate to community research, due to its brevity and fit to a broad demographic spectrum; (3) unique in its ability to cross‐section individuals into risk categories. It should prove useful to community psychologists in determining etiology, diagnosing risk for pathology, and evaluating the efficacy of interventions.     

Treatment Utility of Universal Screening for Behavioral Risk: A Manipulated Assessment Study

In recent years, schools have started implementing preventive practices such as universal screening. Yet, researchers have not evaluated the extent to which universal screening contributes to academic and behavioral outcomes. The purpose of this study was to evaluate the treatment utility of universal screening for behavioral risk. Student participants were randomly assigned to two groups, corresponding to a different method of identification (office discipline referrals and universal screening). Participants identified as at risk, based on their office discipline referral data or universal screening data, and selected for intervention, received a Tier 2 intervention. Data were analyzed using a fixed-effects regression model. Analyses identified no statistically significantly differences between the two groups with regard to various academic and behavioral outcomes, suggesting universal screening did not contribute to changes in student functioning.     

The Partners for Life Program: A Couples Approach to Cardiac Risk Reduction

Morbidity and mortality are reliably lower for the married compared with the unmarried across a variety of illnesses. What is less well understood is how a couple uses their relationship for recommended lifestyle changes associated with decreased risk for illness. Partners for Life compared a patient and partner approach to behavior change with a patient only approach on such factors as exercise, nutrition, and medication adherence. Ninety‐three patients and their spouses/partners consented to participate (26% of those eligible) and were randomized into either the individual or couples condition. However, only 80 couples, distributed across conditions, contributed data to the analyses, due to missing data and missing data points. For exercise, there was a significant effect of couples treatment on the increase in activity and a significant effect of couples treatment on the acceleration of treatment over time. In addition, there was an interaction between marital satisfaction and treatment condition such that patients who reported higher levels of marital distress in the individuals condition did not maintain their physical activity gains by the end of treatment, while both distressed and nondistressed patients in the couples treatment exhibited accelerating gains throughout treatment. In terms of medication adherence, patients in the couples treatment exhibited virtually no change in medication adherence over time, while patients in the individuals treatment showed a 9% relative decrease across time. There were no condition or time effects for nutritional outcomes. Finally, there was an interaction between baseline marital satisfaction and treatment condition such that patients in the individuals condition who reported lower levels of initial marital satisfaction showed deterioration in marital satisfaction, while non satisfied patients in the couples treatment showed improvement over time.     

The Identification of Early Risk Factors for Severe Emotional Disturbances and Emotional Handicaps: An Epidemiological Approach

Epidemiological methodology is used to examine the relationship between early childhood risk factors and future identification as having a Severe Emotional Disturbance or as having an Emotional Handicap (SED/EH) at age 13. Data were obtained from 1979/1980 Florida birth records that were electronically linked with 1992/1993 Florida school records. An epidemiological perspective was chosen due to its ability to model both individual and community-level risk. In regards to increasing an individual's risk of SED/EH, two factors, gender (being male) and low maternal education (mother not completing high school at the time of the child's birth), were found to have particularly strong effects. When examining effects of these risk factors upon overall rates of SED/EH in the community, maternal education and marital status (being unmarried at the time of the child's birth) were associated with a large proportion of the cases. Health/biological markers were moderately associated with SED/EH on the individual level, but were related to a relatively small percentage of cases in the population. In addition, effects varied based upon ethnic/cultural heritage. Researchers are encouraged to consider using an epidemiological perspective and its potential utility in the field of community psychology and public policy is discussed.     

Efficacy of self-administered treatments for pathological academic worry: A randomized controlled trial

Research on treatments for reducing pathological worry is limited. In particular, academic worry is a common theme in generalized anxiety disorder (GAD) samples as well as non-clinical student samples. Given the high cost of anxiety disorders to society, research is needed to examine the efficacy of self-administered treatments designed to reduce pathological worry. The primary goal of this study was to investigate the benefits of three self-administered interventions for reducing academic worry. College students (N = 113) experiencing clinically significant academic worry were randomized to either: (a) worry exposure (WE); (b) expressive writing (EW); (c) relaxation consisting of pulsed audio-photic stimulation (APS); or (d) waitlist control (WLC). Participants were instructed to practice their interventions three times per week for one month and completed home practice logs online to track treatment adherence. Academic worry, general anxiety, and perceived stress were assessed at baseline and post-treatment. Academic worry and general anxiety were also assessed at a three-month follow-up. Those assigned to the WE and APS conditions showed significant improvement relative to EW and WLC at post-treatment. All treatment conditions showed continued improvement by follow-up, with no between-group differences. Treatment and public health implications are discussed.     

A Sensemaking Approach to Ethics Training for Scientists: Preliminary Evidence of Training Effectiveness

In recent years, we have seen a new concern with ethics training for research and development professionals. Although ethics training has become more common, the effectiveness of the training being provided is open to question. In the present effort, a new ethics training course was developed that stresses the importance of the strategies people apply to make sense of ethical problems. The effectiveness of this training was assessed in a sample of 59 doctoral students working in the biological and social sciences using a pre–post design with follow-up and a series of ethical decision-making measures serving as the outcome variable. Results showed not only that this training led to sizable gains in ethical decision making but also that these gains were maintained over time. The implications of these findings for ethics training in the sciences are discussed.     

The Linguistic Therapy of Evaluation: A Treatment Plan for Silvia

This paper describes the treatment of a depressed woman, Silvia (I. Caro, 2001), treated with the linguistic therapy of evaluation. The linguistic therapy of evaluation is a type of cognitive psychotherapy developed from the theory of general semantics. The theory and the treatment are based on the use of language and the role this plays in the development of emotional problems such as anxiety and depression. We briefly describe the main conceptual and assessment issues of the therapy and the procedure followed in the case of Silvia. The aim of the therapy is to change patients' evaluations, that is, to help them to develop an extensional orientation instead of an intensional orientation, which is assumed to be at the core of emotional problems. The paper ends with a brief review of the process and outcome research that has demonstrated the efficacy and the clinical process of the linguistic therapy of evaluation.     

The Prophylactic Mastectomy Dilemma: A Support Group for Women at High Genetic Risk for Breast Cancer

The goal of this pilot study was to test the usefulness of a six session psychoeducational support group for women at high genetic risk for breast cancer who were considering prophylactic mastectomy. The themes of the group sessions included overestimation of and anxiety about risk; desire for hard data; the emotional impact of watching a mother die of breast cancer; concerns about spouse reactions; self- and body image; the decision-making process; and confusion over whom to trust in decision making. Both the participants and the multidisciplinary leaders concluded that as a supplement to individual counseling, a support group is a beneficial and cost-effective treatment modality. Recommendations for the optimal format for such a group are described.     

A Standard of Care for the Assessment of Suicide Risk and Associated Treatment: The Florida State University Psychology Clinic as an Example

The Florida State University has established a set of guidelines to be used as a standard of care for suicide. This standard of care guides therapists through a suicide risk assessment that focuses on key variables related to suicidal behavior that are among the best predictors of completed suicide. This standard of care includes necessary components of suicide risk assessment, critical steps to follow to ensure the safety of suicidal patients, treatment recommendations, and guidelines for minimizing the legal risk of the therapist. Though this standard of care was developed in a research and training clinic, these principles may be applied to all clinicians offering psychological services to patients, regardless of the nature of the clinic or setting.     

A Regional Study of Risk Factors for Drug Abuse and Delinquency: Sex and Racial Differences

Many juveniles are at high risk for delinquency and drug abuse by virtue of the characteristics of their neighborhoods, which are often economically impoverished, socially unstable, physically neglected, and rife with crime, drug use, and drug selling. However, a significant proportion of these youth do not engage in deviant behavior, while others participate to varying degrees. This study examined what factors discriminate between high-risk youth who do and who do not exhibit deviant behavior. Self-reported measures of several attitudes and behaviors known to correlate with drug abuse and delinquency were assessed in relation to reports of property offenses, person offenses, drug use, and drug selling. Additional analyses were conducted to distinguish between sex and racial groups to further qualify the relationships between deviant behaviors and attitudes. The most notable finding was that types of deviance that primarily involve material and monetary gain may be largely influenced by relationships with significant others, while deviance with potentially harmful consequences to both self and others are influenced largely by personal attitudes. Examination of individual variables showed that negative peer influences and positive attitudes toward fighting significantly increased the likelihood of reporting involvement in three of the four deviance measures, and that positive relationship with the father and prosocial values were inversely related to two of the behavioral deviance measures. There were very few differences in significant predictors of deviance for males versus females. Several self-reported attitudes and behaviors distinguished African Americans from Hispanics and Whites, even though Whites were reportedly responsible for a higher incidence of deviant behaviors.     

Risk and Protective Factors Associated with Childhood Obesity in a Sample of Low-Income,Single Female,Parent/Guardian Households: Implications for Family Therapists

The United States is in the midst of a childhood obesity epidemic that disproportionately impacts underserved and diverse populations. In this study, in-depth qualitative interviews were conducted with 16 low-income, single, female, parent/guardians of an overweight or obese 3- to 8-year-old from socioeconomically disadvantaged backgrounds. Following the tenets of the thematic analysis approach, interviews focused on identifying risk and protective factors influencing parental and child health behaviors associated with child weight status. Results from the interviews are organized according to the Socioecological Framework to help identify risk and protective factors at various system levels. Findings from this investigation have relevance for family therapists as they can inform clinical and advocacy-focused interventions with disadvantaged families affected by childhood obesity.     

Healing from Moral Injury: A Qualitative Evaluation of the Impact of Killing Treatment for Combat Veterans

This paper evaluates the Impact of Killing (IOK) treatment—a psychological intervention designed to address moral injury and trauma associated with killing in war. Using qualitative data from interviews with 28 combat veterans, we examine IOK’s impact, how it differs from other trauma-focused treatments, and how it can be improved to better meet veterans’ needs. We found that many veterans processed their killing experiences for the first time in IOK, even though all had previously completed evidence-based treatments for posttraumatic stress disorder. Several described killing in war as the most distressing and transformative trauma of their lives, and all affirmed the value of an intervention focused directly and explicitly on moral injury and killing. IOK helped veterans to acknowledge their grief, shame, and distress; gently but critically examine their thoughts and beliefs about killing in war; and make strides toward acceptance, reconciliation, and forgiveness.     

Risk Assessment and Genetic Counseling for Hereditary Breast and Ovarian Cancer: Recommendations of the National Society of Genetic Counselors

These cancer genetic counseling recommendations describe the medical, psychosocial and ethical implications of identifying at-risk individuals for hereditary breast and ovarian cancer (HBOC) through cancer risk assessment, with or without genetic susceptibility testing. They were developed by members of the Practice Issues Subcommittee of the National Society of Genetic Counselors’ Familial Cancer Risk Counseling Special Interest Group. The information contained in this document is derived from extensive review of the current literature on cancer genetic risk assessment as well as the professional expertise of genetic counselors with significant experience in education and counseling regarding hereditary breast and ovarian cancer. Critical components of the process include the ascertainment of medical and family histories, determination and communication of cancer risk, assessment of risk perception, education regarding the genetics of HBOC, discussion of molecular testing for HBOC if appropriate (including benefits, risks and limitations) and any necessary follow-up. These recommendations do not dictate an exclusive course of management or guarantee a specific outcome. Moreover, they do not replace the professional judgment of a health care provider based on the clinical situation of a client.     

A Case Study of the Implementation of Outcomes-Based Funding Within a Local United Way System: Some Implications for Practicing Community Psychology

This case study provides an overview of significant organizational change within the United Way system in Franklin County/Columbus, Ohio. Franklin County is a major urban center with a population approaching 1 million. The implementation of outcomes-based funding proved to be a critical factor that served to promote change within the local United Way system. Adoption of outcomes-based funding principles resulted in significant shifts in United Way funding and major policy changes. A chronology of events and stakeholder reactions over a multiyear period are reviewed. The implications of this effort to initiate major, system-level change for the practice of community psychology are discussed.     

Aspects of Activity Participation as Risk Factors for Conduct Problems in Children and Adolescents: A Literature Review Using Ecological Systems Theory

This article reviews a wide range of risk factors associated with the development of conduct problems in children, with a particular focus on the influence of time spent engaged in different types of activities. The review reveals the behavioral benefits to children and adolescents of participation in activities with physical, social, and restful properties and those that can be described as structured. Further highlighted is the need for parents and occupational therapists to be aware of children's time use and daily activity participation, and the potential for these activities to be harnessed to facilitate positive behavioral outcomes for children.     

Global Collaborative Team Performance for the Revision of the International Classification of Diseases: A Case Study of the World Health Organization Field Studies Coordination Group

Background/Objective: Collaborative teamwork in global mental health presents unique challenges, including the formation and management of international teams composed of multicultural and multilingual professionals with different backgrounds in terms of their training, scientific expertise, and life experience. The purpose of the study was to analyze the performance of the World Health Organization (WHO) Field Studies Coordination Group (FSCG) using an input-processes-output (IPO) team science model to better understand the team's challenges, limitations, and successes in developing the eleventh revision of the International Classification of Diseases (ICD). Method: We thematically analyzed a collection of written texts, including FSCG documents and open-ended qualitative questionnaires, according to the conceptualization of the input-processes-output model of team performance. Results: The FSCG leadership and its members experienced and overcame numerous barriers to become an effective international team and to successfully achieve the goals set forth by WHO. Conclusions: Research is necessary regarding global mental health collaboration to understand and facilitate international collaborations with the goal of contributing to a deeper understanding of mental health and to reduce the global burden of mental disorders around the world.     

Trauma Recovery in the Transgender and Gender Diverse Community: Extensions of the Minority Stress Model for Treatment Planning

Transgender and gender diverse (TGD) populations, including those that do not identify with gender binary constructs (man or woman) are increasingly presenting for treatment of posttrauma sequelae. Providers who offer services for trauma survivors including posttraumatic stress disorder (PTSD) treatment should be knowledgeable about evidence-based care and have some cultural familiarity with TGD experiences. Indeed, the Minority Stress Model suggests that the combination of distal and proximal minority stressors can combine to produce increased mental health symptoms as compared with cisgender peers, though this model has yet to be fully tested. Clients often present with a complicated picture of experiences, which include a variety of minority stressors, microaggressions, discrimination, and traumatic events that can all be related to their identity. However, conceptualizations of trauma treatment in the context of extensive minority stress are lacking. This paper summarizes the existing literature and offers guidance to mental health providers who are well positioned to address stigma, discrimination, violence, and related symptoms that arise from micro-, mezzo- and macro-level spheres of TGD individuals’ experience.