Basic Biopsychosocial Framework.
Last updated: 3 October 2025
This post explains the framework used in the biopsychosocial model. While the framework is a powerful analytical tool, a description can sometimes make it seem abstract and disconnected from real life. I introduce the building blocks one by one, asking you to imagine real-life situations. I focus on the structural aspect, the fundamental components. The model considers the relationships between different elements, and some of these relationships are demonstrated. The basic model includes direct, indirect, interactive, and bidirectional relationships! It is mathematically complex and unpredictable. Fortunately, it is the structure behind the model that is most important in clinical analysis of specific situations.
Table of Contents
Introduction
Illness is a challenge. How do we decide whether someone is unwell? What personal or environmental factors influence whether someone seeks healthcare? How do we investigate the apparent increase in the UK of people unable to work due to disability?
Our brain solves most problems by using a model of the situation to understand its nature and determine the best course of action. It will generate a model, even if it lacks any firm evidence; if action is needed, it must have some way of predicting the effect of an action.
Thus, if we notice an unexpected change in our bodily experience or function, we may seek the cause, which involves using our explanatory model of health. In the distant past, our ancestors attributed ill health to spells cast by witches, miasma, the Gods, the effects of travelling by train (the Victorians suffered ‘railway spine’), and many other factors.
Models of health, illnesses, and healthcare underlie all political and policy decisions. Unfortunately, most people do not realise this and automatically use the culturally dominant biomedical model. In 2004, Peter Halligan and I asked, Do biomedical models of illness make for good healthcare systems? We demonstrated biomedical models had failed, but with little effect!
One reason may be that explanations of the biopsychosocial model are off-putting. However, it is currently the only holistic and person-centred explanatory model available. A model requires a structural framework defining the classes of phenomena concerned, and this is sufficient to use it. Therefore, this post focuses on the structure.
Systems.
Before starting, I will discuss systems, as a basic understanding of systems and systems theory is helpful. Most people have a vague appreciation of systems, if only to say “It’s the system’s fault that …”
A system is a group of interactions or inter-relationships that form a whole. A hospital is a collection of departments that collectively form the hospital, and the hospital is a system. However, a department of surgery is itself a whole, comprising many groups, such as the theatre suites, inpatient wards, administrators and managers, surgeons, and others. Thus, it is also a system that will interact with various other systems within the hospital, including radiology, the Department of Medicine, and the Pathology Department.
The key feature is that most systems are part of a hierarchy, with systems below them and others above them. For instance, the hospital is a member of a regional group, which in turn is part of the NHS, and so on.
The concept of systems was first developed in 1913 by Alexander Bogdanov, who referred to it as Tektology. Twenty-four years later, in 1937, Ludwig von Bertalanffy published his General Systems Theory. During the same era, General Jan Smuts published his book, Holism and Evolution, in 1926; he is credited with coining the term.
These ideas contributed to the development of the biopsychosocial model of illness. Saad Nagi developed initial ideas in 1969 (discussed in The Disablement Process), but the crucial publication was by George Engel, who coined the term in 1977 in “The Need for a New Medical Model: A Challenge for Biomedicine.“
Most healthcare services claim to be holistic and patient-centred. To achieve this, one needs an analytic model or framework that encompasses all systems relevant to a person. Many healthcare services, such as internal medicine or orthopaedic surgery, are primarily based on a biomedical model, which focuses on identifying and treating diseases.
Therefore, this introduction to the biopsychosocial model starts with the person.
The person.
Imagine you are a guest at a friend’s wedding. You find your allocated table for the meal, where you do not know anyone except your partner, sitting opposite. How do you usually introduce yourself to other people at the table, or later when relaxing over coffee?
Almost certainly, you will explain your relationship with the bride or groom, mentioning the networks where you met and got to know each other, such as work, school, or hobbies. Then you are likely to discuss your work, primary interests, hobbies, and your family. You are extremely unlikely to mention your health, the presence of symptoms, or your ability in activities such as dressing or running.
If you did have pain, you would say, I am in pain and explain where it is felt and what it is like. If you had just fallen and fractured your arm, you would not say that the pain was in your brain, even though the brain is the main organ generating the feeling. Ultimately, you would consider that you, as a person, suffered the pain that arose from the broken bone.
Interpretation
The person is the integration of all bodily parts, functions, and appearances; he or she is not a separate entity. In other words, the person encompasses mind and body. You do not separate your mind from your body, even if you believe the brain is the main organ generating the sensation and emotion of pain.
Almost everyone introduces themselves through their social roles and networks. They rarely start with their health, and even less often with their functional capabilities.
The example of pain given above illustrates that you consider yourself as a whole, not as a collection of organs. Thus, when talking to or about other people, you will also consider them as a whole: their appearance, clothing, manner of speaking, roles, and interests, among other things. You are unlikely to believe that the person is only their brain, divorced from the rest of their body. If describing yourself, you will say, “I am quite short, and I like mountain climbing.” You would not say, “My body is quite short, but my body is good at climbing mountains.”
The ill person.
I have discussed the meaning of illness in a post, “Disease, illness, sickness, and disability”. I conclude that “the word malady is an all-encompassing word to cover the four concepts we are discussing: disease, illness, sickness, and disability” because it “is not widely used and carries no baggage.”. It is the best non-categorical word for someone who is concerned they may be ill. This section addresses individuals who are worried about their health; they have a malady.
What causes you to see a doctor? It is likely to be a change which has no other more likely explanation. How do you initiate your conversation? You are likely to present your observed or experienced change, including, either initially or after a brief time, your unusual experiences, such as pain. Often, you will also provide a possible cause in terms of a disease.
Now consider how a healthcare professional would describe your problem to a colleague. They will typically give the presumed disease diagnosis and the presented symptoms. They are unlikely to provide any information to a colleague about you.
Interpretation
You and the doctor are discussing your body and what you have experienced. You are both considering, explicitly or implicitly, what part of your body has started functioning differently to cause a change in your body’s functioning.
Thus, the conversation is covering two distinct matters:
- Your body, and the changes you have experienced
- The organs within your body, which you consider the probable cause
Sometimes, the structure of the conversation may imply that you are independent of your body and can report on it ‘objectively,’ as an external observer. For example, you might say, “My arm has pain in the wrist, and my hand is weak,” rather than saying, “I have a painful wrist and weak hand.”
Activities, function.
Typically, but not inevitably, a person with a malady notices a change in their activities and how they function. For instance, dressing may be slower or talking to a friend may be less fluent. Sometimes, other people notice the change, such as the development of a slight asymmetry or limp when running.
Activities are goal-directed behaviours; they are an interaction between a person and their physical and social environment, and the goal may include physical and social components. For example, you may cook the family meal both to prepare the food (a physical goal) and to demonstrate your contribution to family activities (a social goal).
The activity might be a specific response to an environmental feature. For example, at a train station, you may show an official your ticket when boarding the train, and this often happens automatically because you recognise and react to their uniform, without a request.
Activities may also be limited or enabled by features of the environment, such as being unable to converse in a noisy restaurant or being able to access the restaurant because it provides appropriate slopes or lifts.
Interpretation
Activities refer to how a person interacts with their environment to satisfy all needs, from basic sustenance and survival to intangible aspirations, such as increasing society’s attention to people with disabilities. The environment may generate a goal, limit its achievement, or enhance it. They have physical or social consequences, often having both. Activities only occur if the person wants to achieve a goal, and their motivation is crucial. Thus, personal factors also influence activities.
It is crucial to recognise that communication is a vital human activity that primarily achieves social goals but is often also essential when aiming for a physical outcome.
Environment.
Imagine two friends or relatives who have had accidents that leave them with similar losses: a non-dominant arm with loss of all nerves due to a brachial plexus injury, leaving it flaccid and useless but (fortunately) with no pain. One is a 22-year-old man injured in a motorcycle accident at speed, the other a 58-year-old woman who fell while going down a flight of stairs and hit her shoulder on an object, causing the injury.
Are they likely to have similar outcomes? Which of these two people will, five years later, be more satisfied and why? What would you want to know when answering?
You would want to know a great deal, such as:
- What work do they do?
- Do they live alone?
- Are they emotionally strong or easily discouraged?
- How have they reacted to previous accidents?
- What is their financial situation?
Interpretation
The suggested items cover much more than just the physical and social environments already mentioned. Some of the additional features relate to personality, others to experience, etc. The broad range of relevant factors is more accurately described as encompassing contextual considerations.
The context.
People often overlook the crucial role that the environment plays in our lives. For most animals, the physical environment is predominant. Nevertheless, in some species, the social environment has a significant influence. This includes, for instance, bees, wolves, chickens, and great apes.
Humans have additional intangible environmental influences, such as their age, available financial resources, access to other resources, previous experiences with similar situations, and social support.
Thus, it is better to refer to contexts rather than simply the environment because most people equate the environment with the physical environment and overlook the other aspects.
The four relevant contexts are:
- Physical, extending from immediate (e.g. clothes, cutlery) to the locality and region, and also encompassing climate.
- Social, extending from immediate family or people living in the same accommodation, through friends and colleagues, to regional and national features.
- Personal, which encompasses a vast range of phenomena from beliefs and attitudes, through previous events and experiences on to goals and expectations
- Time, with two sub-divisions:
- Stage in the person’s life (age), which influences many matters such as responsibilities and resources
- Stage in the illness, which influences their knowledge and expectations, and the likely future.
Social context.
Earlier, I asked how you introduce yourself to a group. You might point out that how you introduce yourself depends on the situation. At a chess club convention, you are likely to focus on which team or club you are in and any roles you may have, such as treasurer. Moreover, there are situations, such as a medical outpatient consultation, where it is entirely appropriate, indeed expected, to discuss your symptoms or, sometimes, the activities you have difficulty with.
I now ask you to imagine that a surgeon has been working in your hospital for ten years, serving as the clinical lead and considered an expert in their field. They have a high status. When, however, someone discovers that their medical qualification was a forgery and they have no actual medical qualification, they immediately lose their job and role, despite their clinical excellence. Their new role is as a criminal.
Interpretation
These issues all demonstrate the importance of the social context, encompassing both local and broader national cultures. Moreover, the interpretation of a person’s behaviour by an observer depends crucially on social context. The context determines both the expectations others have of the person and the way others interpret their behaviours.
Physical context.
Now, imagine you wish to invite an 80-year-old relative who has Parkinson’s disease, which affects her speech, and she also requires hearing aids, to celebrate your birthday at a restaurant. Would you choose your favourite Italian place, which is always busy? If not, why not?
A busy, crowded venue would be unfair because she would have difficulty hearing in a noisy environment, and her speech is likely to be quiet and challenging to hear. In addition, she might be slow at eating, causing her embarrassment, and struggle to walk between tightly packed tables.
Interpretation
One must consider the person’s physical context and how it may limit or increase their capabilities. This includes everything from peri-personal objects such as clothing, glasses, and cutlery through local structures, such as doorways and stairs, onto the broader environment, such as hills, weather, and access to public transport.
Personal context.
Last, consider how three different people of significantly different ages that you know might cope after sepsis that led to the loss of their non-dominant arm and a long hospital stay, leaving them generally weak. How do you think a host of characteristics associated with them might influence their situation five years later? You might take into account their:
- Personality
- How they managed any other serious illnesses
- Beliefs and attitudes
- Goals, priorities, and expectations
- Resources, such as money, social support, and housing
- Responsibilities, such as to children or parents
Interpretation
Illness is an integral part of someone’s life. Their past and expected future will influence how they adapt to it, as well as the strengths and weaknesses they possess.
Conclusion
The diagram below summarises the framework and the different systems involved. A model is concerned with inter-relationships. The description above, incidentally, illustrates the complexity of the model, as almost every factor can or might influence every other factor. The framework illustrates what may be influencing a particular situation. Determining what is influencing something is challenging because many factors interact with each other. My primary goal is to enhance your understanding and awareness of the biopsychosocial framework, which enables the development of a model in principle.