Abandoning Biological Essentialism: The Biopsychosocial Approach to Psychological Wellness
by: mike morse 03/23/2021
The past few months I have written essays exploring our understanding of mental health and its practice, critiquing the ways in which the Western medical model has introduced itself into our self-care. The term “medical model” itself was coined in 1971 by psychiatrist R.D. Laing, who argued strongly against the model’s use in psychiatry. He argued that psychiatric diagnoses were merely labels of conduct (or behavior), and therefore should not follow a biological treatment. Similarly, Thomas Szasz, a psychiatrist and social critic, believed that mental illness is a “destructive social construct that medicalizes living”; he thought many forms of treatment for mental illness deprived people of their dignity as they removed people’s personal agency. To contrast, the “biopsychosocial model” suggests that biological, psychological (and emotional), and social (and cultural and environmental) components all interact to impact (in this case psychiatric) outcomes. This model, first termed by George Engel, was originally used for general illness and pain, but now has been expanded to include all aspects of wellness, including mental and psychiatric health. By using the biopsychosocial approach, individuals can better understand a full picture of their health, and in turn they can practice more intentional self-care.
In the context of mental health, it’s essential to underline the biological, psychological, and social components that interact with and have led to a diagnosis. For example, let’s say we have a 17-year-old white working class girl (I’ll call her Jane) who recently received an ADHD diagnosis. I’m going to go through each of the three biopsychosocial components to contextualize Jane’s diagnosis and to break down what the process to get this diagnosis may have looked like. Generally, ADHD is diagnosed in significantly higher numbers among young boys, due to the stereotypes associated with the label. Jane likely needed to either show extreme symptoms of dysfunction (such as not being able to maintain relationships, failing in school, acting out, etc) or was able to advocate strongly for herself in order to receive this diagnosis.
Although the biological root of ADHD is not entirely understood, brain imaging has shown differences in the brains of people with ADHD, including in areas of the brain associated with emotion regulation, voluntary motor control, and cognition. Other findings have suggested that people with ADHD have naturally lower levels of dopamine activation and transportation, which would explain the benefits of stimulant medications. I believe that understanding the role neurotransmitters play in a mental health ‘disorder’ may be one of the most helpful ways to change the biological aspects of one’s mental health. Most psychiatric medicines directly target neurotransmitters in one way or another, whether exciting or inhibiting them; I argue that working to balance our neurotransmitters, aka our bodies’ molecular communicators, is one of the simplest and healthiest ways to improve our brain and body’s neurological functioning. ADHD historically has been considered a childhood disorder, which reflects the notion of underdeveloped neurotransmitter regulation, however symptoms of ADHD persist into adulthood for many people, especially if undiagnosed in childhood. In Jane’s situation, as a teenager, she likely has significant trouble regulating her emotions and probably struggles with self-control.
Upon entering her appointment, she described to the school psychologist that she often felt frustrated that she struggled with completing tasks in a timely manner and that this frustration often resulted in violent outbursts towards her younger siblings. She also was worried that she was depressed, as most days the only emotions she experienced were sadness and worry. A psychiatrist should hear these complaints and recognize that the symptoms of Jane’s untreated ADHD, such as her inability to stay on task, are impacting the way she thinks about and perceives herself, and in turn her self-talk (a term psychologists use to describe our internal dialogues and resulting behaviors). Jane’s depression might also be a direct result of her cognitive state (which is built upon her self-talk, thoughts, and feelings). Since Jane was able to identify her violent outbursts as being a direct result of her frustrations with herself, management of this anger will happen concurrently with other behavioral treatment, such as attempts to work on improving attention. Jane’s psychologist will likely choose a treatment plan that combines psychiatric medicine (such as a stimulant medication) and psychotherapy, where Jane can practice changing her self-talk, using a method such as the therapeutic technique known as Cognitive Behavioral Therapy (or CBT, which directly challenges you to change your thoughts and feelings to in turn influence your behaviors).
Finally, we need to think about how Jane’s social environment has impacted her mental health state, and also how her diagnosis will interact with her environment. Jane described herself as working-class; her parents both work full time jobs and often weren’t home until after Jane and her siblings were expected to be done with their homework for the day. However, Jane rarely was able to complete her assignments, and instead spent most of her evenings frustrated over her siblings’ ease with task completion. Jane started receiving lower grades in all of her classes, which is what led to her teacher’s recommendation to see the school psychologist. According to the DSM, someone with ADHD needs to experience their dysfunction in at least two settings, for example at home and at school. Because Jane’s parents were not home enough, they did not see Jane struggling and in fact believed that she may have been acting out. Luckily for Jane, she was able to self-reflect and see the ways in which her struggles differed in her home environment when compared to her school setting. A few months later, Jane was informing her psychologist that she found herself more able to stay on tasks through completion, noticed her violent anger decreased, and even found herself more invested in her friendships than in the past. However, she had noticed that her family was treating her differently after receiving her diagnosis. Jane’s parents had been infantilizing her, giving her more restrictions and curfews while giving her siblings more freedom. Jane believed that her parents viewed her as being ‘diseased’ or less capable than her siblings for some reason; while her day to day tasks had become more manageable, Jane’s depression worsened. Jane would likely continue to attend therapy regularly to process and manage her daily challenges, whether social, psychological, or related to her psychiatric medications.
My main point in writing this example is to show that the intricacies between the biological, psychological/emotional, and social/environmental/cultural factors that impact someone’s mental health can shift with time. I want to emphasize the importance not in the model itself, but in recognizing that a multitude of factors influence an individual’s cognition, emotions, and behaviors. In fact, even the term “biopsychosocial” is limiting, as we also need to consider historical, cultural, and environmental impacts on people. In this example of Jane, I had to reference the DSM, as it is the primary psychiatric diagnostic manual in the United States; however, it should be critiqued for its medicalized and militarized roots. These labels are socially constructed and should not be considered end-all-be-all identity labels for those struggling with their mental health management; instead they can be used as tools for exploring one’s thoughts, feelings, and actions.
People living outside of America who experience similar behavioral and emotional symptoms would not necessarily receive the same diagnoses we use in this country. Variations in language influence the ways in which people internalize and process their own state of being; cultural differences determining one’s place in their society create unique barriers and expectations for behavior. While mental health diagnoses can act as an aid or guide for treatment of behavioral dysfunction, no two people will have identical experiences. Additionally, any changes we make to ourselves and our behaviors will also influence all of our biological, psychological, and social domains.
Although this framework seems to be particularly focused on mental health, it’s important to note that the biopsychosocial approach can be used across all forms of wellness. Even with regards to physical health, social, environmental, and emotional factors can change the ways in which our bodies process and engage with treatment. Understanding the concepts behind the biopsychosocial model of wellness is not just helpful for gaining a full picture of our health, but can be further used as a guide to understand the ways in which our socially constructed society has come into existence. It can also be helpful to use when considering the ways in which we exist in a constant state of creation, rather than one that is stagnant or biologically predetermined. Life is a process of constantly adapting and evolving; the influence of humans on the Earth and all its other life is obvious evidence of this. By recognizing all biopsychosocial influences on all living things, we can see more clearly how all things are connected; all of our choices and actions have consequences, whether they are immediately obvious or not.
Self-care involves allowing ourselves to slow down, reflect, and process our behaviors, emotions, thoughts, and feelings. Self-care is purposefully sitting in discomfort in order to grieve and heal. In order to allow ourselves to fully engage in healing, whether psychological or otherwise, it is essential that we abolish any approaches to care and wellness that are rooted in a framework that ignores our modern overlapping oppressive social systems. We cannot care for ourselves or others if we are tied to a biological essentialism of any kind. Diagnostic labels can provide joy, and they can cause pain; they should not form one’s whole identity. We should instead be focusing on the broader neurodiversity that exists normally among all people; rather than framing mental health care as treating illness, we should recognize and accept the differences that exist in all of us.
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