B-2 Using the biopsychosocial model
Last updated: March 16, 2025
The biopsychosocial model of illness is the crucial framework for all rehabilitation practice – clinical, managerial, quality improvement, and research. Learning to use the biopsychosocial model of illness is challenging because the biomedical model is culturally dominant and is ingrained from early childhood, reinforced by the education and training most healthcare professions receive at the beginning of their career. Nonetheless, it is possible, and teaching and learning strategies can help. The primary way to make it second nature is through daily use and practice; it needs to become the default model, the dominant personal model. I am not suggesting that the biomedical model should be abandoned; it should be reserved for use in appropriate circumstances and within the broader use of the biopsychosocial model. This page discusses how this competency can be achieved – and why it must be.
Table of Contents
The competency
The trainee uses and explains the biopsychosocial model of illness in all situations relating to rehabilitation.
Introduction
All rehabilitation experts must be excellent at using the biopsychosocial model of health in everything they do. The biopsychosocial model is the vital underlying theory for all rehabilitation decisions and analyses, just as the biomedical model is the central theory underlying traditional medical practice.
Many pages on this site discuss the model and its application in rehabilitation and a table lists and has links to all pages with significant content. I have published articles about the model since 1987, when I wrote about its use in neurological rehabilitation. This page will focus on why this competency is essential and the evidence that training can help.
Using the biopsychosocial model - why?
Rehabilitation initially concerned the consequences of a person’s disease, tissue damage, or condition. The World Health Organisation’s International Classification of Impairment, Disability, and Handicap, published in 1980, explicitly concerned the consequences of disease: “The International Classification of Impairments, Disability, and Handicaps (ICIDH), developed in the 1970s, was issued by the World Health Organization in 1980 as a tool for the classification of the consequences of disease (as well as of injuries and other disorders) and of their implications for the lives of individuals.”
However, many diseases are now well managed, if not cured. Despite this, demand for healthcare has increased, and this cannot all be attributed to the direct consequences of disease.
Since the biopsychosocial model of illness was first published in 1977, people have increasingly understood that much illness is multifactorial. Although there may be a primary causal factor, many other factors influence the presentation and consequences of the initiating factor. Moreover, it is now evident that up to 25% of people presenting to hospital and more in general practice present with an illness without any primary causal disease; they have functional illness.
This realisation leads to terminological difficulties as the meaning of disease as the primary cause is diluted. I have discussed the terminology used to distinguish between some different aspects of ill-health in a post:
- Malady, a non-specific term encompassing unwellness
- Illness, a person-centred term encompassing the experience of ill-health
- Sickness, a societally-centred term validating the role of being unwell
- Condition, a non-specific term encompassing a patient group based on a factor such as symptoms or disabilities
- Disease, a subset of condition where the unique cause for the condition is known
Diagnosis is a further challenging term, often used as if synonymous with a single cause—for instance, the diagnosis of a fractured femur. However, one might also refer to the diagnosis of obsessive-compulsive disorder, which does not have a single cause. More recent diagnoses such as fibromyalgia are even less unitary, covering many interrelated symptoms and many contributing factors.
Rehabilitation plays a leading role in managing people with functional disorders, chronic disease, and other multifactorial maladies because of its expertise in analysing multifactorial illness and planning multi-component tailored interventions delivered over a significant period. Rehabilitation focuses on the person and uses the biopsychosocial model of illness to analyse and formulate the patient’s situation and then to plan interventions. This contrasts with the biomedical approach, which focuses on symptoms and uses the biomedical model to discover and treat the assumed primary cause.
Thus, an excellent understanding of the biomedical model of illness and its use in analysing and treating complex illness is crucial; without it, rehabilitation fails. This competency is vital.
Biopsychosocial model validity.
A cynic might argue that the model is just common sense made complex, and that there is no sound basis for learning about and using it.
Common sense is necessarily based on a framework or model. Most people use the biomedical model as a framework because it is culturally dominant, and common sense would fail unless it used a better model. The biopsychosocial model of illness provides the necessary framework. I have reviewed the evidence concerning its validity in several journal articles, notably on many pages on this site, such as here.
In an empirical investigation into effective rehabilitation, I have also shown that using the biopsychosocial approach is the central feature of effective rehabilitation. It is used extensively in rehabilitation research and as a structure for guidelines, further proving its practical validity.
The need for all members of a multi-professional rehabilitation team to base all their individual and team processes on the biopsychosocial model cannot be doubted.
Training in using the biopsychosocial model.
Studies have been conducted on training healthcare professionals to use the biopsychosocial model of illness. These studies usually investigate healthcare professionals in a particular field of practice, such as musculoskeletal rehabilitation, although some concern doctors in psychiatry or general practice. There is no reason to believe that the findings from these studies would not apply generally.
Tina McClain and her colleagues studied biopsychosocial formulation in psychiatry residents (trainees) in centres across the United States. They found that few residents reached a basic level of competency in making a biopsychosocial formulation of a case; worryingly, there was a trend towards lower competency as trainees gained more experience.
More optimistically, an intervention to increase competency led to measurable improvement in the centres implementing the intervention. The intervention included:
- Highlighting the low competency of residents at grand rounds (presumably in a supportive, developmental manner);
- The programme director meeting with faculty members to ask for increased attention to training the skill;
- The programme director meeting with residents to emphasise the importance of learning the skill.
Ingrid Scholten and her Australian colleagues reported twelve tips for teaching the biopsychosocial approach, presumably based on their experience. The ones I think are relevant are:
- The trainer needs to improve their understanding and use of the model
- The skill needs to be a way of thinking and practising in all situations (i.e. a worldview)
- Learning about the model must be integrated in all parts of the curriculum
- Fostering inclusive partnerships, talking about and using the framework with others
- Incorporate teaching into all other teaching activities
- Undertake education in both uni-professional and multi-professional contexts
- Incorporate its use in all clinical activities
Phoebe Simpson and her multinational colleagues recently published a scoping review on training physiotherapists (physical therapists) to treat people with pain using individualised interventions based on the biopsychosocial model. Their findings revealed 36 studies. Only 24 gave information about the training content, which was very varied. Only 12 studies included any competency assessment, and the methods used varied. They summarised the findings “There was a large disparity in the biopsychosocial interventions and training approaches, ranging from didactic educational “top-ups” to training with experiential learning, feedback, supervision, and post training mentoring.”
The review focused on teaching professionals how to use the model to undertake a specific treatment rather than training them to use the model in all areas of practice. However, this method may be more effective, as it is practical rather than theoretical.
A study of students investigated how training in the model, as applied to patients with low back pain, altered their attitudes and beliefs and whether it influenced their patient management. It found that it changed their attitudes and affected their treatment and advice to patients.
Last, a recent systematic review by Wendy Ng and her Australian colleagues investigated barriers and facilitators affecting the adoption of a biopsychosocial approach with patients who had chronic pain. They classified these factors into three groups:
- The micro-level factors relate to the individual practitioner. They range from personal beliefs and knowledge to misunderstandings of guidelines to concerns about the time involved.
- The meso-level meant organisational influences such as how guidelines were formulated, funding arrangements, and workforce training.
- The macro-level concerning national health policy and social factors.
This is remarkably similar to the influences on implementing patient-centred care.
In summary, there are a few studies on training competency in using the biopsychosocial approach to healthcare, and most of those I found concern managing pain. They suggest that training alters practitioners’ behaviour.
Training/learning lessons.
There is little specific information to take from the available research. The main points I extract for the publications reviewed are:
- Competency is considered essential but is generally found to be low
- Attention to learning and training probably improves competency
- Success is more likely if the competency is used in all settings and is shared with others
- Success depends upon a culture of valuing and using the model
I can report how I learned. From about 1988 for about ten years, I constantly discussed the model for up to 3-4 hours a week with my friend and colleague Peter Halligan, and we debated solid points and weaknesses. Dialogue and debate are potent ways of learning. Second, I used it to structure my clinical letters, reports, patient data collection, research applications, research articles, documents presented to management, and several national guidelines I wrote. Third, I taught about it to many audiences from many different professions. Last I used it regularly with patients and families when discussing their problems.
In other words, it became wholly internalised and remains central to how I view clinical, research, or service matters. Furthermore, the questions, comments, and new ideas proposed by the audience all helped immensely.
There are some general principles:
- You learn and improve through practice, especially using the knowledge and skills in as many different circumstances as possible
- Constructive critical feedback, formal or informal, is essential and includes reflection on your performance.
- Being in a supportive culture and environment where the model is used and valued increases knowledge and skills.
I would recommend that you:
- Read the articles referred to in the pages on this website, and read as many of the pages as you can over time, to see how the model can be used
- Discuss patients with your peers, colleagues, and seniors, basing your discussion around this model
- Arrange multi-professional teaching sessions with your rehabilitation teams to discuss the model and how it might help teamwork.
- Write a detailed formulation on at least three or four patients each month.
- Use it to structure explanations and information given to patients
- Try to develop a culture based on the model within your rehabilitation service
- Teach and lecture about it, especially to doctors from other specialities
Last, you could use the Oxford Case Complexity Assessment Measure (OCCAM) to measure the complexity of the patients you see in your service. When we developed it, we found that if you undertook a complete biopsychosocial assessment for about 25-35 minutes, you could usually fill in the form from the information you garner. If you find areas you always need to catch up on, you will be getting feedback on your use of the model. The paper and some forms can be seen and downloaded.
Conclusion
People have done little research into training healthcare workers in using the biopsychosocial approach to rehabilitation or within healthcare, despite its central importance in rehabilitation and other specialities such as geriatrics, paediatrics, and psychiatry. The limited available evidence suggests that knowledge about and using the approach is limited, but educational interventions can benefit professionals. Most of the advice given here is based on general academic principles. The most important feature is to make the biopsychosocial approach and mindset the cultural norm for all rehabilitation team members.
