George Engel's Contribution to Clinical Psychiatry

The work of George Engel permeates the practice of medicine in the Western world to an extraordinary degree. Engel's thesis was that a physician's need to know and understand must be complemented by an ability to make the patient feel known and understood. That thesis has come to be regarded as common sense, and that which is expected of a doctor. It has helped medicine to remain human in the face of enormous pressures to remain biological. Engel's exposition of the biopsychosocial model [1] epitomized his drive to have all doctors, not just psychiatrists, attend to the patient's culture, psychological being, behaviour and, most importantly, the patient's inner life in a systematic manner. It reflected his years of teaching medical students and residents in all disciplines. It reflected his unique qualifications as an internal medicine physician and a psychoanalyst. It reflected his intense case studies, the most famous of which was that of Monica, an infant with a gastric fistula whom he followed for 40 years, observing the links between her affective states and gastric functioning, and her relationships. It reflected his personal commitment to the entire context of the patient including the emotional needs and development of all with whom he worked.

Many leaders in the field of psychiatry in Australia, including a number who were subsequently appointed to chairs (e.g. Wallace Ironside and Bruce Singh), worked with and were trained by Engel in Rochester, New York. A number of Australian non-psychiatric physicians were similarly trained. Psychoanalysis was well enough developed in Australia for these professionals to find a fertile field for the application of Engel's ideas. Medicine in Australia became biopsychosocial without knowing it, in the way that the Western world became psychoanalytic without knowing it in the 20th century. A generation of Australian medical students and psychiatry trainees have been taught to interview in a way that establishes a context for symptoms and illness, and allows them to produce a full and meaningful narrative answer to the question, ‘why is this patient ill in this way and presenting at this time?’.

This paper focuses on Engel's influence on clinical psychiatry, through the development of the concepts of conservation–withdrawal and the biopsychosocial model and their application in teaching, training and clinical work at the interface of psychiatry and medicine. It also examines the intellectual context of these concepts, and their legacy. We conclude that we are indebted to George Engel for a more comprehensive understanding of how medicine – medicine and psychiatry – should be practiced, for epitomizing the good doctor.

Conservation–withdrawal

Engel's work as a conceptual psychoanalyst and keen clinical observer led first to the seminal proposition of the concept of conservation–withdrawal which he developed with Schmale and colleagues [2]. This was a reformulation of their earlier concepts of the ‘giving-up’ reaction and its component ‘helplessness’ and ‘hopelessness’ dimensions, as elucidated by Sweeney et al. [3]. Engel and Schmale proposed that the affective response of giving-up, when it follows real, threatened or symbolic loss of a highly valued form of gratification or object, tends to precede the onset or exacerbation of somatic as well as psychic disease. They proposed that it facilitates the manifestation of whatever disease potential or predisposition exists in the individual or environment to become. ‘Giving up’ includes a loss of self-esteem, a disruption in object relationships, a decrease in motivation, and an expectation that such a state may be enduring. Helplessness was defined as a feeling of being left out or abandoned where loss of gratification is perceived as caused by external events or objects. With hopelessness, the individual feels that he or she alone is responsible for the loss and that there is nothing that he or she or anyone else can do to overcome it. Engel and Schmale proposed that conservation–withdrawal is ‘the basic biological anlage serving survival’ that comes to be reflected in the behaviour and psychological experience of the human being. Giving up is defined as the ‘inner experience of the person in whom the conservation–withdrawal mechanism has been activated’ [4]. They argued that organisms are confronted, periodically or by chance, with unfavourable environmental conditions, in which a withdrawal rather than an active response is highly adaptive and serves ‘an elemental survival function’. Appraisal of the situation indicates ‘either a too intense input which cannot be assimilated (as overload)’ or ‘a deficient input which indicates an unavailability of supplies (underload)’. In such cases, activity is not only fruitless but is a waste of scarce resources.

Seligman's complementary learned helplessness model of depression, developed contemporaneously on the basis of animal studies, took these ideas further, in that it led to an effective form of treatment for depression; cognitive–behavioural therapy. As proposed originally, learned helplessness produces a cognitive set in which people believe that success and failure is independent of their own skilled actions [5]. Abramson et al. [6] offered a cognitively orientated reformulation of the learned helplessness model of depression that can be seen to have been influenced by Engel and Schmale's work. Abramson et al. argued that people have a characteristic explanatory style, which they tend to apply to events despite the context. Those who have a pessimistic explanatory style were proposed as being especially vulnerable to depression when faced with uncontrollable life stressors. Cognitive–behavioural therapy used hypotheses such as these to develop effective psychotherapy techniques for depression.

There has been renewed interest in the ‘giving-up’ concept. Further work has helped to clarify the distinction between depression and demoralization, and this has become an important issue in the field of physical/ psychiatric comorbidity [7]. To a limited extent, Engel and Schmale's claims that ‘the giving-up process was found as an antecedent to disease of all categories’ [4, p.23] has received empirical support. Depression has been shown to be a risk factor for increased morbidity and mortality [8,9].

The concept of conservation–withdrawal is paradigmatic of the way in which the relationship between psychosocial events and physical status can be addressed within a wider biopsychosocial model; this was Engel's next major contribution.

The biopsychosocial model

Engel's biopsychosocial model is his best-known contribution. It stands as one of the most influential ideas in Medicine in the 20th Century. Engel's claim for the scientific status of the model may draw criticism, but in that it articulates historical clinical wisdom and has stimulated a plethora of conceptual developments, it has become a key motto of medical education and practice.

The model and its claims for being scientific

In his paper ‘The clinical application of the biopsychosocial model’ [10], Engel argued that physicians approach patients and the problems that they present in a way that is very much influenced by the conceptual models in relationship to which their knowledge and experience are organized. He knew that physicians are largely unaware of the power such models exert on their thinking and behaviour. He thought that this was because the dominant models are not necessarily made explicit. Rather they are part of the fabric of education and cultural background which is taken for granted. He described the prevailing model at the time as being ‘biomedical’. He offered his alternative model, the biopsychosocial model. He argued for it on the basis of good medical practice:

“The biopsychosocial model does not add anything to what is not already involved in patient care. Rather it provides a conceptual framework and a way of thinking that enables the physician to act rationally in areas excluded from a rational approach — The reduction-ism and mind-body dualism on which (the biomedical) model is predicated requires that (data) must first be reduced to physico-chemical terms before they can have meaning’ [10].

He claimed that the model was based on a systems approach, and constituted a scientific model constructed to take into account the missing dimensions of the biomedical model, which does not include the patient and his or her attributes as a person.

Engel claimed that the biopsychosocial model would enable the physician to extend application of the scientific method to aspects of everyday practice and patient care not previously deemed accessible to a scientific approach or even deemed worthy of examination, for example, inner feelings. Engel makes the point in his 1977 paper [1] ‘… most recognize how ephemeral and insubstantial are appeals to humanism and compassion when not based on rational principles’. Engel's argument for the biopsychosocial model being a scientific one rested on his observation that the doctor's task is to find out how and what the patient is or has been feeling and experiencing, to formulate an explanation, and to engage the patient's participation in further clinical and laboratory studies to test such hypotheses. The sole reliance on biophysical or somatic data was claimed to be insufficient and would lead to erroneous conclusions. He contrasted the biopsychosocial model with what he described as counter dogmas; those of ‘holistic’ and ‘humanistic’ medicine. He stated that these qualify as dogmas to the extent that they eschew the scientific method and lean instead on faith and belief systems handed down from remote and obscure or charismatic authority figures.

Engel skilfully argued that whether the illness be diabetes mellitus or schizophrenia, it was necessary to include four dimensions: (i) physical, (ii) psychological (including inner feelings), (iii) social, and (iv) behavioural. He claimed that without an examination of all four, sufficient understanding and clinical practice would be truncated and incomplete, and possibly lead to inadequate diagnosis(es) and/or treatment(s). Furthermore, he said, all four dimensions could and should be examined scientifically with the patient as partner. In that sufficient interview skills were necessary on the part of the physician to obtain a comprehensive database in all four dimensions, this proposal had major implications for training in both psychiatric and non-psychiatric medical disciplines.

The biopsychosocial model requires training in a particular type of medical interview. The technique was described in ‘Interviewing the Patient’ which Engel wrote with William Morgan [11]. Engel articulates how the interview is guided by the clinician's conceptual frame of reference – the biomedical or the biopsychosocial. The information queried and obtained will be affected by this orientation. ‘Hence, observation (outer viewing), introspection (inner viewing), and dialogue (interviewing) are the basic methodologic triad for clinical study and for rendering patient data scientific’ [12]. In 1997 Engel once again emphasized the importance of the medical interview not only as a human encounter but also as a rigorous instrument to better understand the patient and help explain the data that the patient presents [13].

We can see that such a theoretical model allowed a reunification of biological models of psychiatric illness and psychosocial models – ‘biological treatments and talking treatments.’ The biopsychosocial model argues for a combination of both. It also argues that a taxonomy built on observable behaviours, such as DSM-IV, even though it has five axes, is really a static triaxial diagnostic schema rather than a biopsychosocial formulation. There is no obligation to discern or integrate the interrelationship of psychological state and trait disturbances (axis I and II) with biological dysfunction (axis III) or stress and social functioning (axis IV and V). In DSM-IV these are regarded for the most part as separate domains, which is reminiscent of the non-integrated triaxial taxonomy developed by the World Health Organization in the 1970s. The integration of biology, psychology, social issues and behaviour, and the interaction among them, is the hallmark of the biopsychosocial model of disease promulgated by Engel. As such, this model moves psychiatry back into being a medical discipline, while at the same time expanding the dimensions and comprehensiveness of other medical disciplines. The biomedical model is too narrow a basis for medical practice. Learned helplessness, illness behaviour, failure to cope, hypochondriasis, somatoform disorders, psychological factors affecting physical illness, somatization and non-compliance are all examples of problems that confront the practitioner of medicine and Engel's model allows them to be researched, taught, and incorporated into clinical practice.

The intellectual context of Engel's biopsychosocial model

The psychosomatic medicine movement of the mid-twentieth century espoused many of these notions inherent in the biopsychosocial model, but failed to enunciate them in a convincing way [13,14]. ¹ It took seriously the concept that what is uniquely human is the capacity to assess one's mental state. It readily embraced psychoanalysis as a tool. That alienated psychiatry from the rest of medicine and from biological psychiatry, both of which became caught in rationalism. In embracing psychoanalysis as its tool, psychosomatic medicine employed explanatory concepts of folk narrative; concepts like love, hatred, fear, belief, feelings of weakness and dependence, etc. [15]. But it failed to sufficiently examine another Engel contribution – the ‘Somatopsychic Phenomenon’. [16]. This formulation stated that just as psychosocial issues may affect the body, for example, stress and an acute asthmatic attack, bodily processes (somatic processes) can and do affect the mind, for example, delirium from a fever or metabolic imbalance. Much of the psychosomatic effort was directed to the mind to body axis, ignoring the fact that medical illness can have untold effects on the central nervous system and the mind, as exemplified in HIV patients. The somatopsychic phenomenon is important in all of psychiatry, and especially so for the consultation–liaison psychiatrist.

1

The psychosomatic movement and the relationship with traditional psychiatry training and practice in Germany is an excellent example of the split between the biomedical model and the biopsychosocial model in the medical setting. Specially trained psychosomaticists (internists also trained in psychoanalysis) manage psychosomatic problems, and have their own hospital beds and units, while psychiatry attends the more biologically focused illnesses, e.g. psychosis. Consultation–liaison psychiatry has come only lately to Western Europe and Germany with considerable reluctance to perform this medicine–psychiatric interface work in traditional German departments of psychiatry.

Lipowsky, a major North American psychiatrist, also conceptualized the relationship between biological, psychological and social factors, but did so within the psychosomatic medicine paradigm, which he defined as comprising an approach, a science, and a set of techniques [17]. Psychosomatic medicine as an approach was said to have as its hallmark the insistence that psychosocial as well as biological factors be considered in the diagnosis, treatment and prevention of all diseases. Psychosomatic medicine as a science was said to study the relationship between psychological and biological phenomena as they occur in, and are influenced by, the social and physical environment, in both health and disease. Psychosomatic medicine as a technique was said to involve the clinical application and teaching of the psychosomatic approach, with a particular emphasis on the art of consultation. Psychosomaticists were the advocates of the biopsychosocial approach, they aimed at studying the field scientifically, and they needed skills in communication. Lipowsky made no claims for the scientific properties of the biopsychosocial model, but was very influential in providing consultation–liaison psychiatry with a conceptual framework. He moved beyond traditional consultation to the idea of the care-taking team: the consultation–liaison psychiatrist was a key member of the team that taught and practised psychological medicine of the medically ill. Lipowsky was an important force urging psychiatry to consider the body as well as the mind, particularly in the medically ill. He assisted the move of the biopsychosocial model to psychiatry, in particular, consultation–liaison psychiatry.

Balint, a Hungarian psychoanalyst who had migrated to England, explored similar issues with groups of general practitioners in London, but did not use the term biopsychosocial. However, like Engel, he believed that it was important to study these complex issues in a systematic way. His book, ‘The doctor, his patient and the illness’ [18], first published in 1957, summarizes his systematic studies using action research. It led to the identification of important concepts, such as that of the ‘basic fault’ and the ‘deeper diagnosis’, which have become pivotal in working with doctors in understanding what they do. Other important concepts to emerge were those of the ‘apostolic function of the doctor’ and the ‘doctor as drug’. It gave us a model of investigation, ‘the Balint Group’, which has been used widely ever since. By facilitating the group's exploration of their free associations and feelings about the material presented, Balint was able to allow these general practitioners to see that their preoccupation with physical diagnosis and authoritative prescription was often a defensive reaction and did not meet the needs of their patients. One might think that it would not be necessary to demonstrate this 40 years later, but those who work with general practitioners in Balint groups report that little has changed. It seems that although modern medical education emphasizes the biopsychosocial approach, it requires something other than the didactic approach to allow doctors to understand the nature of the doctor-patient relationship. It is as if doctors require ongoing psychotherapy, that is, ongoing working through of issues that have to do with unconscious processes.

Balint's book [18] also discusses the concept of illness behaviour which was later elaborated by Mechanic, Pilowsky and others in a development of Parson's concept of the ‘sick role’ [19,20]. It is there in Engel's ‘The clinical application of the biopsychosocial model’ [10], where he expands on the concept that the patient's tasks and responsibilities complement those of the physician. The concept of illness behaviour, like that of the biopsychosocial model, has had a great influence on Western medicine. What a patient makes of his or her symptoms is what determines what they do about them, and about any advice given to them. Doctors learn this through bitter experience. In the introduction to the millennium edition of Balint's book [18], Michael Balint's son John, Professor of Medicine and Director of the Center for Medical Ethics at Albany Medical College New York, argues that the rise in patient autonomy and the controls imposed on doctors by a market-driven philosophy have altered the doctor-patient relationship in a way that can be traumatic for both. As doctors are forced into partnerships with patients, there is an even greater need for them to understand the forces that work in shaping that relationship.

Teaching the model

In a major pedagogic contribution: ‘The biopsychosocial model and medical education: who are to be the teachers?’ [21], Engel examines the issue of who would be the optimal teachers for this model, and what was the place of psychiatry in it. It is important to note that he as an internist and trained psychoanalyst had directed the Medical Psychiatry Liaison Fellowship at the University of Rochester School of Medicine for 33 years and mentored more than 150 fellows from diverse medical disciplines. Engel believed that role models and teachers should come from within the discipline currently studied by the students, residents or fellows, (e.g. internal medicine, primary care, obstetrics-gynaecology). He believed that psychiatrists could be the primary messenger to a cohort of such medical teachers (the secondary messengers) who would be the direct teachers to the practitioners – the tertiary messengers. ‘… I like to refer to these “mutants” as the cyclic AMP – the “second messengers” of the educational process’. He felt that the gap was too great for psychiatrists to be the direct teachers of future medical practitioners in individual disciplines. He envisaged the Engel Fellows to be the second messengers –the ‘mutants’, and the pedagogic model for promoting the biopsychosocial model throughout all medicine. It is important to note that in a study to develop a taxonomy of mental health training programmes for primary care physicians reported by Strain et al. [22–24], after a site visit for the National Institutes of Mental Health to Rochester, New York, the teachers in the Engel fellowship programme made it clear that Engel fellows – the second messengers – would not perform complicated psychiatric treatments for complicated psychiatric illnesses, but would rather refer the clinical care of such patients to psychiatrists.

In addition, Engel believed that such ‘mutants’ would have an impact on psychiatrists as well, promoting the biopsychosocial model for psychiatric consultations, patient evaluation, and treatment strategies. The important message for psychiatry here was to find and help develop key individuals within medical specialties as a peer group conversant with the psychological, psychiatric, social and behavioural aspects of patient behaviour; that teaching them would be the most optimal approach to facilitate learning with non-psychiatric medical specialties.

The Balint–group members could be secondary or tertiary messengers in the Engel model. However, Balint, a psychiatrist, was teaching primary care physicians, most likely practitioners and perhaps some teachers. Balint has shown that with this group of self selected primary care physicians the distance between psychiatrist and internist is not too great to have knowledge and role modelling bridge the gap. Similarly, Lipowsky has the psychiatrist as teacher in his consultation–liaison model.

Strain (a psychiatrist) and Hamerman (Chairman of the Department of Medicine, Montefiore Hospital, Albert Einstein College of Medicine) developed a programme where an internist and a psychiatrist would co-teach on a medical ward during ongoing medical rounds [25,26]. The internists were especially hand picked from the Department of Medicine and especially trained to identify biological, psychological and social issues that were seminal for patient care. Both the psychiatrist and internist would interview the patient and present their formulation of the patient in front of the medical students, interns and residents. These rounds were held weekly on all the medical units and the internal medicine physician attending became known as the Ombudsman (a Scandinavian word implying ‘wise man of the village'). Similar rounds were established at the Mount Sinai Hospital, New York, with the Chairman of Medicine and the Director of the Consultation–Liaison Psychiatric Service as co-teachers performing weekly biopsychosocial teaching rounds on the medical wards. They also occurred on the otolaryngology service with the Chief of the Service serving as ombudsman. These teaching models were conceived to enhance the chance of the teaching to be seen as relevant by the students on the medical service, since an important attending consultant from their discipline (medicine, otolaryngology) was a co-teacher. It was conceived that the teaching inoculum had a better chance of taking when a teacher of the same discipline dispensed the biopsychosocial issues.

One of the criticisms raised is that Engel offered no evidence of the efficacy of such teaching. Goldberg and other British colleagues [27] have made a systematic study of how general practitioners interview patients with unexplained medical symptoms. They have shown that it is possible to change the physician's interview behaviour and for them to institute therapies that permit patients to reattribute their somatic symptoms and relate them to psychosocial issues. The underlying principles are similar to those enunciated by Engel in his biopsychosocial model.

In his classic text, ‘Psychological Development in Health and Disease’ and in other papers, Engel argued for the use of patients from services other than psychiatry in teaching psychological medicine to junior medical students [16,21]. That has characterized undergraduate medical teaching in Australia, and has become even more pertinent as psychiatric services withdraw into becoming services for psychosis only. Another important point made by Engel was that we must respect the range of personal experience of medical students.

Pain as an example of the application of the model

Engel made a major contribution to our understanding of the concept of psychogenic pain in an early and seminal paper which illustrates how long the incubation period of the model was [28]. By application of his contextual interviewing technique, he obtained a dense narrative which allowed him to identify a number of recurring patterns in the childhood of patients presenting with chronic pain that had not responded to conventional treatments. These included a history of physical or verbal abuse, a history of differential patterns of punishment by parents, a history of being rewarded for illness or pain, a history of guilt for perceived responsibility for pain in others, and a history of deflecting the aggression of parent towards others onto the self. Even as late as 1987, when the DSM-III-R was promulgated, the category of pain in psychiatry's taxonomy was limited only to the psychological dimension – conversion pain. There was no bio or social part of the formulation. With DSM-IV pain was reformulated to include pain from a pure biological source, combined psychological and biological aetiologies, or unknown sources. This is an example of expanding psychiatry's nomenclature toward a biopsychosocial template.

Consultation–liaison psychiatry as a service example of the model

Consultation–liaison psychiatry had its origins at the time when Engel was developing his ideas. It was his energy in reminding doctors of their responsibilities beyond the biomedical model that helped consultation–liaison psychiatry establish itself as the specialty most able to help physicians employ the biopsychosocial model in their practice [29]. Engel referred to the debt that he paid to his colleagues in the medical–psychiatric liaison group at the University of Rochester. Engel's original debt is to John Romano, a psychiatrist who taught Medicine at the Peter Bent Brigham, Harvard Hospital in Boston. This influence continued when Romano took Engel to the medical school at the University of Cincinnati. Engel continued his psychological learning in psychoanalysis in Chicago. George Engel thus had had outstanding training when he assumed his post at the University of Rochester.

It is our belief that consultation–liaison psychiatrists are the second messengers as teachers in psychiatry – the ‘mutants’ in Engel's language [21]. They are not like ordinary psychiatrists in that they are both conversant and comfortable with medical illness, medical drugs, medical settings, and talking with non-psychiatric physicians and medical care teams. Perhaps as few as 5–10% of psychiatrists are really comfortable working/teaching/treating in the acute care medical setting, particularly high tech. settings such as CCUs, ICUs and transplant psychiatry. It appears that consultation–liaison psychiatry came to this concept of the need for a hybrid teacher especially as it moved from the consultation setting to the liaison setting where the psychiatrist joined the team as a co-teacher and co-clinician. Although we do not think this is an Engel or biopsychosocial offspring per se, the concept fits beautifully into his model as to whom the teacher should be; a specially trained psychiatrist – a mutant, for which consultation–liaison fellowship or advanced training is designed.

The response to the biopsychosocial model

Criticisms

A number of challenges to the model were mounted. Schwartz [30] challenged the assumption that the more information that is collected and the better the information is organized, the better will be the diagnosis. He also questioned the prediction of the biopsychosocial theory that treatments will interact with each other as well those with the person and his environment. McHugh [31] was among many who proposed that the biopsychosocial model is so broad in scope and so non-specific in its relation to any particular disorder that its main value lies in reminding doctors to be prepared to look at everything, and interactions of everything, when seeking an explanation of any disorder. He described the biopsychosocial concept as heuristically sterile, having no rules, no directions and no logical pathways to validate and explain categorically distinct disorders put forward in the current psychiatric classifications. McHugh argued that Engel's biopsychosocial model constituted Adolf Meyer's concept of psychobiology renamed and reanimated for the contemporary era. He argued that both Meyer's and Engel's concepts were a reaction to the emerging neo-Kraepilinian manifestations that came to be DSM-III. Engel acknowledged the relevance of psychoanalytic theory and the psychosomatic movement, including Meyer's contribution, but argued that these could not be formalized into a system compatible with the biomedical model. McHugh [31] delineated his thinking regarding perspectives for a new theoretical formulation for psychiatric patients. The dimensions are: (i) life narrative – life story; (ii) personality; (iii) behavioural descriptions; and (iv) biological. In his view such a global formulation as biopsychosocial is not sufficiently specific to be utilitarian for a new psychiatry. McLaren [32], writing in the Australian and New Zealand Journal of Psychiatry, also declared the biopsychosocial model to be flawed as an explanatory model, while granting that it served the purpose of being a valuable public statement about the scope of medicine's domains of enquiry.

Empirical studies on the model

Most authors who have offered criticisms call for further work on the model rather than its dismissal. The work cited below is indicative of more specific examination of aspects of a global theory rather than just promoting a concept – biopsychosocial, and an intervention – interviewing. Complexity is now accepted as a challenging theoretical problem, requiring useful solutions in the health care area as much as in other areas of human endeavour [33]. There is a need to resolve the conflict between biological psychiatry, which postulates the primacy of matter, and psychology, which postulates the primacy of ideas. Model development [34], and empirical studies on the measurement of doctor–patient interaction [35] and on the interaction of biological, psychological and social interventions [36] are useful responses to this challenge. The empirical value of understanding has been explored. There is a considerable literature on the research of process in psychoanalysis [37]. It suggests for instance, that accuracy of interpretation correlates with good outcome. But there is an enormous amount of research that needs to be done if the active ingredients of psychoanalytic or indeed any psychotherapy are to be dissected out and what part they play in a biopsychosocial (Engel) or a perspectives model (McHugh) determined.

Patient-centred medicine as an alternative paradigm

No matter what psychological model is used to support the study of the dimensions and interactions implied in the biopsychosocial model, the concept of the subject is at the core. By ‘the subject’ we mean modernity's ‘personal identity’, usually elaborated as the ‘I’ of my discourse for whom everyone and everything else is an object. What has happened to the subject in postmodern Psychiatry? Is it still a legitimate field of enquiry? Rationalism, manifested as behaviourism in the mental health disciplines, has been the competing intellectual category of the late 20th century. It teaches us not to be able to understand ‘irrational’ phenomena. One is ill or not ill. One has a disease (DSM-IV) or does not have a disease (Not in DSM-IV). In the field of philosophy, postmodernist deconstructive thought has provided an ally to behaviourism in also devaluing the notion of ‘know thyself. Such postmodern philosophy denies that desires, beliefs, emotions and feelings are necessary for the explanation and the occurrence of mental states [15]. The concept of patient-centred medicine has emerged as a dominant paradigm opposing this movement, particularly in the wider health field [35]. It includes the biopsychosocial perspective, but sees this as insufficient for a full understanding of the patient's experience of illness. This seems to be a semantic problem; the biopsychosocial model as enunciated by Engel, Pilowsky and Balint certainly emphasizes the importance of the patient's narrative of self-understanding. This is an important perspective in McHugh's formulation as well. The field of patient-centred medicine has produced a large number of systematic studies and a number of tools for measuring the concepts involved. Patient-centred medicine also includes the issues of autonomy, patient as partner, enhanced interviewing skills to elicit key patient information, etc. This seems to be what Engel envisaged. Psychoanalysis continues to explore ways of exploring the subject. Lacanian psychoanalysis in particular addresses the formation of the subject, rather than simply taking it for granted [38].

The World Health Organization Quality of Life Project epitomizes the surge of interest in the concept of patient-centredness, and in production of instruments to identify and measure what matters to the patient [39]. Quality of life in Medicine is within the biopsychosocial model. It is an important part of the psycho (how I feel), and social (what can I do, and what can be provided for me?). The emergence of qualitative research as a legitimate form of scholarship reflects the way in which Engel's ideas have international currency in areas far beyond medicine. Engel's work has eased the way for qualitative research to be accepted in medicine. That indicates how perceptive he was in realizing that the world was ready to explore the human condition beyond the reductionist model. This is becoming more difficult within medicine.

Current medical funding systems impede our capacity to practice the biopsychosocial model of diagnosis and treatment [9]. Limitation of services on the basis of arbitrarily defined definitions of ‘serious mental illness’, and lack of funding for liaison services between psychiatrists and physicians, have led to the demedicalization of the implementation of the biopsychosocial model. Moves to promote ‘general practice psychiatry’ may help redress such problems, but only if the focus is broader than that of psychosis. Such moves would need to address the fact that in the current structure, the average physician visit time of 15 min or less allows insufficient time to attend to the full dimension of the somatic issues for which the patient sought out the doctor.

Conclusions

‘Medicalization simplifies and is a powerful anodyne to the dreadful pain associated with guilt, responsibility and blame. It is a matter of measure and emphasis – we have swung too far. Don't medicalize unless there is a strong reason to do so – ideology and economics are not strong enough reasons.’ [15].

This quote from a philosopher epitomizes the way in which the concepts of the biopsychosocial model have come to influence a domain beyond that of health. Engel's enunciation of them, and his personal skills in exemplifying them, allowed many similar voices to reach their target. There is much to be resolved about complexity, but the will to do it is there.

Engel's resolve was to bring the totality of the patient together again and carefully consider five dimensions: biological, psychological, social, cultural, behavioural. Each dimension could influence another, and what may appear in one dimension, may really be the result from another. It would take a skilled and highly trained interviewer to carefully review each dimension, and to know their interrelationships, and the power that they have for influencing each other. Although the template has been regarded by some as too vague and not sufficiently specific, the force of his argument for Medicine and Psychiatry can only be applauded. Engel is neither a ‘splitter’ nor a ‘joiner.’ No sector can be ignored when trying to understand what is happening in any other sector. He has brought the patient back together again and shown Psychiatry the essentialness in having a multipronged approach to the patient. Psychosomatic, somatopsychic, purely psychological, and purely biological probes will not hit the mark of patient distress or disease. The psychiatric and medical patient must be observed from multiple perspectives in order to hit the mark of correct assessment and the formulation of treatment strategies. Engel has illuminated the path away from mind-body dualism, missed diagnoses and unmitigated suffering from isolating the wrong dimension. The world, medicine, psychiatry, and our patients are in a better place for his conscientious life long striving to perfect a model that would serve the human being to better his or her wellbeing. To George Engel we are indebted for a more comprehensive understanding on how medicine– medicine and psychiatry – should be practiced. His practice epitomized the good doctor.