19Chapter 16. The Biopsychosocial Model: An Attempt to Piece Together the Mosaic

By the mid-1970s, psychiatry found itself in a peculiar position. On one hand, it wielded an impressive arsenal: chlorpromazine and its successors had transformed the lives of millions; lithium prevented bipolar relapses; tricyclic antidepressants alleviated severe depression. Yet never before had the discipline’s boundaries been so blurred.

Within psychiatry, several incompatible paradigms clashed in a fierce battle. Who among them held the truth? The biological school struck first. Mental illness is a disease of the brain. Find the faulty neurotransmitter. Administer the medication. Everything else is just poetry. The psychoanalysts countered from another front. Illness is the conflict of the unconscious. Tell your story on the couch. The past will resolve itself. Antipsychiatry delivered a devastating blow. There is no illness! Only a social label. And it’s slapped by a repressive society onto those who stand in its way. The behaviorists entered last. Forget the brain. Dismiss the subconscious. Let’s simply retrain behavior. Four portraits of madness. Four ways to break a person—or to heal them. Who among them is right?

Each of these schools had its own department, its own journals, its own conferences. A medical student who chose psychiatry essentially had to belong to one of them—and regard the others as adversaries.

Patients suffered for it. If they saw a biologically oriented doctor, they’d receive medication and hear: “Your relationship with your mother isn’t my specialty.” An analyst would listen for fifty minutes three times a week—but wouldn’t stop their hallucinations. A behaviorist taught them to mask symptoms without asking how they felt. No one saw the whole person.

At that moment, a voice came from an unexpected quarter. It was not the psychiatrist speaking, but a pathologist and internist from the University of Rochester.

George Libman Engel (1913–1999) had an unorthodox career. Trained in medicine at Johns Hopkins, he specialized in pathology, internal medicine, then psychoanalysis. In his forties, he became fascinated by how mental states influenced physical illness—studying ulcerative colitis, psychogenic pain, cardiovascular disorders. He observed identical biological pathologies unfolding differently between patients, realizing the difference lay in their psyche and social circumstances.

In 1977, Engel published an eight-page article in the journal Science titled “The Need for a New Medical Model: A Challenge for Biomedicine.” That article has now been cited tens of thousands of times. It is one of the most influential medical publications of the twentieth century.

Engel articulated it this way: modern medicine, he argued, rests on a biomedical model. This framework reduces illness to biological defects—genes, biochemistry, anatomy, physiology—and works brilliantly for infections, trauma, surgery. But it has blind spots.

It ignores the person who is ill. It disregards their subjective experience of disease. It overlooks how social context—family, work, culture, access to resources—shapes illness onset and progression. It fails to see healthcare itself as both a biological and social construct.

For some conditions, Engel stressed, this gap is critical. Take diabetes: blood sugar control depends not just on insulin, but on diet, adherence to treatment, family support, and medication access. The same applies to schizophrenia—its biology is real, but its course, relapses, prognosis, and quality of life aren’t just biology.

Engel proposed a model he termed the biopsychosocial model. According to this framework, illness arises from the interplay of three levels of factors:

— Biological factors (genes, brain neurochemistry, the endocrine system, immune status, physiological characteristics).

— Psychological (personality traits, cognitive styles, coping strategies, past trauma, psychological resources).

— Social factors (family environment, professional setting, culture, access to healthcare, economic situation, level of stigma).

Three levels: biological, psychological, social. They aren’t stacked layers—they’re intertwined like blood vessels. Tug one, and all tremble. Watch. Social level: Job loss. What follows? Psychological level: depression. Biological? Cortisol shifts. Immune function alters. A lost job silently reshapes the body—no permission asked. And it’s not one-way traffic. Reverse it. Start antipsychotics (biological). Communication improves (psychological). Return to work (social). Three levels. One impact. Three ripples.

Engel’s 1977 paper had the effect of a revelation.

Psychiatrists, weary of the civil war raging between different schools of thought, finally found a common conceptual language—one that didn’t dismiss any approach but rather integrated them. A biologist could keep studying neurotransmitters, a therapist could continue listening to patients, and a social worker could still help with housing and employment. All of them were working toward the same goal: helping the patient by seeing them as a whole.

The model quickly became orthodox. By the 1980s, it had permeated all psychiatric training programs, textbooks, and guidelines from professional associations. The American Psychiatric Association fundamentally reformed its classification system—with the DSM-III in 1980, psychiatry, for the first time, obtained more or less rigorous operational criteria for diagnoses, unaffiliated with any particular school. This was a direct realization of the biopsychosocial ideal: a diagnosis should be consistent enough to be made identically by a biologist and a psychoanalyst when examining the same patient.

For the patient, the biopsychosocial model represented a comprehensive approach. In practical terms, this meant the following: any competent psychiatrist today, when seeing a patient experiencing their first episode of schizophrenia, must address questions across all three levels.

Biological: which medications to prescribe, at what dosage, and how to monitor them? Are there any comorbid somatic conditions? What about substance use—drugs and alcohol? Is there any family history?

Psychological: What was the patient’s personality like before the illness? Their education, interests? How are they experiencing the illness itself? Do they have any traumatic experiences? What defense mechanisms do they employ? Do they need psychotherapy—and if so, what kind?

Social: Who does the patient live with? What’s the family atmosphere like? Do they have a job, go to school, have friends? How does the family react to the illness? Do they have access to quality care? What’s their insurance situation? Are they at risk of social exclusion or homelessness?

Only after answering all these questions does the doctor formulate a treatment plan. And this plan is always multi-layered: medication plus psychotherapy plus family therapy plus social rehabilitation.

To be honest, the biopsychosocial model has its fair share of critics.

The main criticism leveled against it is that the model is too broad. It posits three levels that interact—but how exactly? Through what mechanisms? With what force? At which stage of the disease does each level dominate? The model provides no direct answers to these questions.

In his book The Rise and Fall of the Biopsychosocial Model (2010), psychiatrist Nassir Ghaemi puts it bluntly: the biopsychosocial model has become clinical platitude. Every psychiatrist dutifully lists the three levels when drafting a treatment plan, but in reality, decisions are made intuitively, without strict methodology. Instead of a “universal bio-psycho-social approach,” Ghaemi advocates for pluralism: using whichever model best fits a particular diagnosis.

This criticism has merit—but it’s open to interpretation. For everyday clinical practice, the biopsychosocial model is still the best tool we have. It reminds doctors that a patient isn’t just a sum of biochemical reactions. A patient is a person living in society, with their own history, experiencing illness in their own way. That simple truth is all too easy to forget during a rushed ten-minute consultation.

And here we must speak of a subtle danger that has loomed over the model in the twenty-first century.

In recent years, under the banner of the “biopsychosocial approach,” something has been spreading through psychology and psychiatry that Engel himself could never have imagined in his worst nightmares. Namely: a fuzzy eclecticism that gathers everything under one roof—from evidence-based methods to outright pseudoscience.

Now open the website of your average Russian “integrative psychologist.” You’ll read something like: “I employ a comprehensive biopsychosocial approach. My practice combines cognitive behavioral therapy, psychoanalysis, Hellinger family constellations, regression hypnosis, ancestral trauma work, and transpersonal experiences.” Impressive, right? The text throbs with weighty terminology. Biopscyhosocial. Cognitive-behavioral. Transpersonal. Every second word seems lifted from a respectable medical dictionary—the scientific backbone appears solid. But look closer. Take a skeptical breath. Every third term is outright pseudoscience. A carefully concealed landmine dressed in science’s white coat.

Here’s the trap. The biopsychosocial model isn’t a free pass for eclecticism. Remember that. It’s not an indulgence. Not license to mash together whatever you like. It’s an invitation to view the patient from multiple angles—multiple, yes, but every perspective must be scientifically valid. Every single one. No exceptions. And this is where the sleight of hand begins. Subtle. Almost imperceptible. You can’t pass off “past-life negative programming” as the “social dimension.” You just can’t. That’s not social. That’s not any valid dimension. It’s fiction. Fiction wearing respectable terminology as camouflage.

Real biopsychosocial treatment looks different. Its anatomy is mercilessly precise. Brain chemistry. Medications hammered into international treatment guidelines. Plus meticulous rewiring of the mind: evidence-based psychotherapy—cognitive behavioral, exposure therapy, psychodynamic—each deployed with surgical precision. Add systematic restructuring of kinship bonds: family interventions built on clinically validated models. The multifocal scalpel of systemic family therapy. Psychoeducation excising the tumors of ignorance. Then reintegration into society through proven rehabilitation programs. Supported employment models. Assertive community treatment. A patchwork of disconnected practices? No. Four interlocking components forming an integrated system. Proven tools working in concert. This is modern psychiatry.

Pseudoscience masquerading under the lofty banner of “biopsychosocial approach” is a metastatic tumor in medicine’s body. It erodes, poisons, and destroys patient trust in authentic care. Picture this: two years lost. Two years marching into the trap of “integrative therapy” with some “psychology practitioner.” Two years drained by mantras. What happens behind closed doors? Sleight-of-hand rearranging figurines. A guttural voice “cleansing ancestral karma.” Trance states to “process past lives.” And crucially—no relief. Emptiness. Two years evaporated, pain unchanged. What does this person do? They step outside squinting coldly at all psychotherapy. Their eyes show the scorched emptiness of betrayal. Now they believe all “psychology” is pure charlatanism.

Our profession must safeguard the biopsychosocial concept from those who abuse it. Protect it by enforcing strict qualifications for psychologist and psychotherapist credentials. Protect it by requiring evidence-based methods in practice. Protect it by legal consequences for malpractice.

None of these safeguards exist across most post-Soviet territories today. Thus spreads the pandemic of quackery—precisely because the seductive phrase “biopsychosocial approach” shelters too much that’s utterly unscientific.

But these are themes for later chapters. For now, I’ll close on a hopeful note.

The biopsychosocial model, for all its flaws, remains the 20th century’s grand achievement. It restored psychiatry’s view of the whole person. It demolished the false dichotomy of “either brain or soul.” It made unthinkable that old world where biologists and psychoanalysts glared at each other across walls of hatred.

These days, when a patient walks into the office of a competent psychiatrist in any European country, they know they’ll be asked not just about their symptoms, but about their life. That they’ll be listened to. That their family, their job, their relationships — all of it will be taken into account. That they’ll be offered more than just a pill.

This is already a great deal better than things were at my Baku clinic in 2000, where a patient was given a sulfazine cross and that was considered the end of the matter.

But we’re still far from the point where this model actually works everywhere. Not least because a whole generation of self-styled “healers” has wedged itself between scientific psychiatry and the patient, promising quick happiness in exchange for money.

We’ll get to them very soon. But first, one necessary stop. You can only sit in judgment on the impostors if you present your own code. Let’s look at what rules the profession has worked out for itself — and what those rules are actually worth in practice.