From: Engs, R.C. [Ed.] Controversies in the Addiction Field. Karol L. Kumpfer, Eric P. Trunnell, and Henry 0. Whiteside, Chap. 7: "The Biopsychosocial Model: Application to the Addictions Field."
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CHAPTER 7 The Biopsychosocial Model: Application to the Addictions Field
Karol L. Kumpfer, Ph.D., Eric P. Trunnell, Ph.D., and Henry 0. Whiteside, Ph.D.
A growing understanding that health and disease are determined by complex interactions among biological, psychological and sociological factors (Leigh and Reiser, 1980) has led some researchers (e.g., Engel, 1977; von Bertalanffy, 1974; Keye and Trunnell, 1986; Keye and Trunnell, 1988; Trunnell, White, Pederson, and Keye, 1989) to propose an alternative to the biomedical model. One of the authors (Kumpfer, 1987), after increased exposure to this mode of thinking among psychiatrists who had moved beyond the traditional medical model, proposed in 1987 the Biopsychosocial Model of Vulnerability to Substance Abuse. A biopsychosocial model is a reasonable way to incorporate most causes of alcohol and drug abuse into a single model. Our proposed biopsychosocial model is essentially a macro framework which can be used to integrate complementary and occasionally competing micro theories. This chapter reviews the biopsychosocial model and its historical roots in theory, specific application to addictions, guiding principles, and research and clinical advantages.
Researchers, primarily in behavioral medicine (Schwartz, 1982), have recently promoted biopsychosocial models applied to health sciences, in response to the need for more complex, interactional and contextual paradigms. Schwartz (1982) believes a major paradigm shift is moving the health sciences away from single-cause, linear models to multi-cause, interactive models.
Within the history of theory, Pepper (1942) has identified four different "world hypotheses" or approaches to explanations of nature. Gholson and Barker (1985) have linked these ways of thinking or constructing reality to Kuhn's "paradigms." These four paradigms include:
1. formistic or categorical "black- white" thinking,
2. mechanistic or single-cause, single-effect, orchains of single causesthinking,
3. organicistic or multi-causal, integrative and holistic thinking and
4. contextual or relational or transactional thinking.
Later, Pepper (1967) proposed a fifth world view, selectivism, to account for intentional, meaningful functioning, and goal-directed behavior. This view and contextualism are reflected in the transactional perspective as proposed by Altman and Rogoff (1987), which is based on the earlier distinctions made by Dewey and Bentley (1949) between interactional and transactional perspectives. Behavior is viewed as an integral part of the person and their environment. The unit of analysis is not just the person but an integration of elements in the environment and the person, resulting in his or her behavior.
Because ofthe multi-causal nature of addiction, understanding chemical dependency within a framework restricted to only a formistic and mechanistic world hypotheses offers little in the way of explanation or prediction. Unfortunately, the traditional biomedical model is primarily a mechanistic, linear model, which does not account for the complex experiences of individuals or their social context. Engel (1980) argued that the conceptual models used by clinicians to organize their knowledge strongly influence their interactions with patients, the data they collect, and their diagnoses and prescribed treatments. Because the dominant models guiding practice are rarely made explicit in clinical training, most clinicians are blind to the power such models exert on their thinking and behavior.
Where's the Person? Critics of the biomedical model argue that the biomedical model depends on a linear, single causal, physics model of science at the expense of the humanity of the patient (Engel, 1977; Engel, 1978; von Bertalanffy, 1974). This "robot or zoomorphic" model of man was a predominant view in the industrial age (von Bertalanffy, 1974). Ironically, this nineteenth century positivistic model was abandoned by the hard sciences early in the twentieth century, but has continued to dominate thinking in the social and behavioral sciences. Partly because of this "physics envy", even American psychology was dominated in the first half of this century by the concept of man as a reactive organism. Human behavior was thought to be completely predictable, or "trainable and conditionable." Even early treatments for alcoholism tried to condition patients to avoid alcohol. This mechanistic, conditioning approach simply did not work. Unmotivated patients "hot-wired" their conditioning by mixing the alcohol to which they had been Reconditioned with different mixers or fruit juices, and continued drinking.
Humanistic Psychology. Considered a "third force" in the psychological study of humankind (after psychoanalysis and behaviorism), humanistic psychology tries to understand people in context, in total, or whole, as did Gestalt theory. Humanistic psychology proposed to study:
1. the healthy rather than the sick as the basic model,
2. people, developmentally over time and
3. people within their natural context. Humanistic psychology promoted the idea of an equal emphasis on protective or resiliency factors as compared to the primary emphasis on risk factors found in the biomedical model.
General System Theory. System theory (deRosnay 1979; Miller, 1978) provides a metatheoretical framework for more specific biopsychosocial models. Systems theory asserts that the behavior of any person or system can be understood only by the interaction of the many different hierarchical levels or systems impacting that person. A system is defined by deRosnay (1979) as a "set of elements in dynamic interaction, organized for a goal" (p.65). Weiss (1977) argued that systems theory is best understood as the logical ordering of nature into more and mole complex systems. Each level or system of an organism (e.g., genes, cells, tissues, organs, nervous system, person, dyed, family, community, culture) is part of a more complex unit.
Schwartz (1982) identified different academic disciplines with each of these system levels. For instance, geneticists study chromosomes; cardiologists study organs; psychologists study individuals, dyads, and families; and sociologists study groups, communities, and cultures. He believes that systems theory can help break down the traditional boundaries between disciplines in the biomedical and behavioral sciences through biopsychosocial integration.
Need for An Integrated Theory. The need for a more integrated, interdisciplinary approach to the study of organisms is becoming more apparent. This need has reached critical mass in the "war on drugs", where the different "warriors" come from many different disciplinary fields. Within the interdisciplinary addictions field, no clear "paradigm shift" has occurred. The field appears to be in a "pre-paradigm phase." There are currently many different camps of devoted followers. Some genetic psychiatrists, forexample, believe that genetic engineering will eventually solve the "drug problem"; AA-trained paraprofessionals believe that belief in a Higher Power and social support can cure alcoholics; doctors believe that drugs can cure drug dependency; and psychologists and social workers believe that psychotherapy will cure the patient.
Kuhn did not account for this lack of a single, mutually acceptable paradigm or way of thinking, but later writers have. Lakotas (1981) discussed a "pre-paradigm phase" as having several research programs and Laudan (1981) discussed the concept of "research traditions" consisting of families of theories that evolve gradually based on "core commitments" and empirical data (Gholson and Barker, 1985).
The biopsychosocial model offers an integrated conceptual framework useful to all professionals and researchers in the addictions field. The authors' proposed biopsychosocial vulnerability model (Figure 7.1) is one potential macro theoretical framework helpful in organizing etiological factors for substance abuse.
Biological Factors. Several authors (Kumpfer, 1987; 1989; Goodwin, 1985) have reviewed the growing body of literature on the biological correlates of vulnerability to alcoholism and drug dependency. These reviews suggest that a large number of biological factors can predispose a person to alcohol or drug dependency. The authors ' proposed biopsychosocial model includes three major cluster factors of biological variables:
1. genetic inheritance of different alcoholism syndromes (malelimited, milieu-limited, depression-sensitive), differences in metabolism and reactions to alcohol and other drugs, biochemical and neurological vulnerabilities, and temperament (ANS) differences, or cognitive (CNS) structural differences.
2. in utero damage to the fetus that could result in central or autonomic nervous system problems, and/or physical and biochemical damage that could make a child temperamentally or psychologically more vulnerable to alcohol or drug use, and
3. temperament or other physiological differences that could occur at anytime after birth due to sickness, accidents, physical trauma, improper diet, exposure to toxins, or alcohol or drug use.
These biological cluster variables are temporally ordered with genetic factors preceding in utero or later physiological damage to the child's biology. Additional biological cluster or individual variables could be added to the framework as discovered by empirical research.
The presence of any one of these biological conditions is generally not sufficient for the expression of alcoholism ordrug dependency later in life. When a number of these biological factors converge and interact with nonsupportive and negative environmental conditions, however, these "diseases of life-style" can emerge.
Psychosocial Factors. The major psychosocial environmental clusters included in the author's model are organized temporally into family, community\school, and peer\social cluster factors each containing an underlying cognitions, stress, coping process model (see Kumpfer and DeMarsh, 1985) as follows:
1. family variables include family attitudes and values, which interact with family stressors (i.e., conflict, poverty, parent, or sibling use of drugs), as buffered by positive family coping skills and resources (i.e., communication, problem solving skills, life skills, and external social and material support).
2. community\school variables including community\school attitudes and values towards prosocial activities and alcohol or drug use, which interact with community\school stressors (i.e., poverty, high crime rates, high population density, impersonal climate, discrimination, conflict or noncooperation and support, pressures to use drugs), as buffered by coping skills and resources (i.e., positive leadership, good problem solving skills, education, prevention, and treatment resources).
3. peer\social variables including peer attitudes and values towards prosocial activities and alcohol and drug use, which interact with peer stressors (i.e., peer conformity pressure, developmental adjustment issues, poverty, lack of emotional or material support, depression and poor mental health, lack of opportunities, academic, job and social adjustment problems) as buffered by peer coping skills and resources (i.e., social support, effective group problem solving, conflict resolution and communication skills).
These cluster variables are also temporally ordered by major sources of influence developmentally as the child matures. Family factors are primary and earliest in their sustained impact on the infant and youth. As the child matures and goes to school, school and community environmental factors have more impact. Eventually peer influences predominate, becoming the final common pathway to alcohol and drug use in youth (Dielman et al., in press; Elliott, Huizinga, and Ageton, 1985; 1989; Kumpfer and Turner, in press).
Literature reviews have also found research support for the impact of environmental factors on vulnerability to alcohol and drug dependency. Most researchers (Bry et al., 1982; 1987; Hawkins et al., 1987; Kumpfer, 1987) now accept the hypothesis that the more risk factors, the greater the vulnerability to drug abuse.
Principles of the Biopsychosocial Model. The explicit and implicit philosophical underpinnings and principles of the biopsychosocial model are the following:
1. Causation is multi-directional, multi-causal, probablistic, and sensitive to initial dependencies (as in chaos theory).
2. Changes in one aspect of the person-person or person- environment system can reverberate throughout the system.
3. Reciprocal transactions occur between the person and the environment.
4. The person is influenced by future events and is goal- directed (Bandura, 1989). Actions are purposive and intentional. People actively initiate events and try to minimize disruption to the system.
S. The person does not always move towards an ideal state, as in organicistic theory, but can also be self-destructive.
6. To be understood, the person must be pragmatically studied in relationship to his or her total unique context, including historical, current, and future factors.
7. Idiosyncratic events should also be studied.
8. The meaning of events to the person should be understood.
9. Attempts to study and measure the person\environment system change the system, hence there is no such thing as independent observation as proposed in positivistic theoretical research.
10. Longitudinal, developmental, ethnomethodological and anthropological research methods are needed to study such organicistic and transactional systems.
11. While a grand synthesis of general theory may occur, there are likely to be many exceptions based on the complexity of the system. Variability and novelty do occur. because each person and event is different in a transactionallv related system.
Interactional vs. Transactional Aspects of the Model.
Before discussing the proposed biopsychosocial model, we would like to briefly make explicit the distinction between interactional and transactional views. This is based on the work of Altman and Rogoff (1987) and Dewey and Bendey (1949). Factors related to an individual's functioning, from an interactional view, are seen as separate and discrete entities, each impacting on the other in an unidirectional manner. Whereas, from a transactional view, these factors act on and are acted upon each ocher in a dynamic and reciprocal manner. The first view, interactional, is mechanistic; while the second view, transactional, is contextual and organicistic in nature (Altman and Rogoff, 1987).
Other authors in psychology, although not explicidy stated, have proposed similar views to the transactional view. For example, Bandura's (1978; 1986) reciprocal determinism views the "interaction" among behavioral, environmental, and person factors in a bidirectional, temporal manner.
The proposed biopsychosocial model is an organicistic model widh transactional elements. As shown in Figure 7.1, there is considerable interaction between and within dhe biological and psychosocial factors. For example, family environmental factors, such as parenting style, family stressors, and family resources can have an "interactive" effect on the physiological and temperament characteristics in the child. This means chat dhe child's temperament will also change the family environment. These proposed bi-directional influences have been substantiated in relational studies of children and their parents (Lewis and Lee-Painter, 1974). A temperamentally difficult child or, indeed, any child has an impact on his or her family, school, and peer environment.
Many biopsychosocial models have been criticized for still subordinating psychosocial factors to biological factors (Armstrong, 1987; Day, 1985). However, the proposed model places as great an emphasis on environmental factors as on biological factors.
The model incorporates all perceived and nonperceived aspects of the person's life. It is a "person-person and person- environment" system chat is continuously changing over time and with critical events. This model goes beyond the interest of transactional models in events to an interest in tile continuing interaction of the person widh his or her biology and psychosocial environment. Developmental maturation principles apply as the person matures. The system operates by moving towards ideal states, homeostasis, and balance, but occasionally aberrant directions can occur, such as destructive tendencies. The meaning of She process should come from the perspective of the person, which the observer may never completely understand.
Another principle incorporated in the model is self determinism. Psychologists and sociologists are beginning to challenge the linear deterministic model of human behavior and replace it with notions of reciprocal determinism (Bandura, 1986) and a type of deterministic free choice in which people choose or shape environments to impact themselves in certain expected ways (Bandura, 1989). To support a drug habit, a high-risk child may drop out of school and get a job, working with other young drug users. Whereas a low-risk child may choose to save money to assure that he or she can attend a private religious college where alcohol and drug use are very low.
Likewise, the environmental realms of influence are not necessarily sequential or linear. Kumpferhas empirically tested this part of the model with the "Social Ecology Model of Adolescent Alcohol and Other Drug Use" using structural equations modeling (LISREL) statistics (Kumpfer end Tumer, ingress). Afterpublication, the model was tested in reverse and found to almost be as good a fit. Since structural equations modeling analyses presume a linear order, it is not possible to simultaneously test interactive bi-directional models. Reversing the order of the variables produced suggestive evidence that youths' choices of peers were as likely to impact their relationships to school, community, and family as the family environment was to impact their school and peer environments.
Research methods and statistical techniques to test interactive and, eventually, transactional models are needed. Because of the complexity of the model and the requirements for a large data set with multiple time samples, empirical testing of the model will be difficult.
Implications for Prevention and Treatment
The major mandate of the biopsychosocial model is that the clinician understand the person in relation to his or her total biopsychosocial environment. The clinician should approach the collection of diagnostic data and development of a treatment protocol from this expanded framework. Without a complete understanding of the unique causes of addiction within a particular person, any proposed treatment regime is likely to be ineffective. A complete Patient Evaluation Grid (PEG) (Leigh and Reiser, 1980) as recommended by Schwartz (1982) would help the clinician to gather more complete data for diagnosis and treatment planning. The author has developed a risk assessment instrument for doctors' use that includes most of the major biopsychosocial risk and protective factors in the research literature. This instrument is based on the biopsychosocial model and can be found in Dr. Robert DuPont's recent OSAP Monograph (see Alta Institute Risk Assessment in Appendix in DuPont, 1989).
This approach could stimulate in clinical' practice the gathering of a more comprehensive set of data and possibly improve empirical assessment and diagnosis. As pointed out by Schwartz (1982), however, there is little data to prove that taking this comprehensive, global approach will improve assessment. Some practitioners "miss the trees by focusing too hard on the forest." It would only seem logical, however, that systematically collecting data on the major known precursors of alcohol and drug abuse should increase the accuracy of prediction and diagnosis.
Many prevention specialists are currently attempting to develop methods for assessing the level of risk and protective factors in children and youth in order to target precious prevention services to those who need them most. This paper recommends that such risk and protective factor assessments include data on biological, psychological, and social factors—primarily family, school, and peer groups.
One major implication of this model for prevention is that prevention interventions targeting any part of the person- environment system or person-person system should also impact central determinants in many parts of the system. This reverberation concept of a transactional model makes the effectiveness of many different types of prevention interventions look more promising. Reverberation means that prevention specialists do not have to isolate a single, most influential cause that will prevent youth from using or abusing drugs. Many different types of prevention interventions targeted at different points in theperson\environment system Annie likely to be effective. The more mutually reinforcing and coordinated the interventions, the more the impact. However, interveners must understand the total impact of their prevention approach on the person and the total environmental context. In some cases, a particular prevention strategy could have negative impacts on other parts of the system and result in increased drug use.
A biopsychosocial model of addiction is a very useful conceptual framework for integrating the different causes of alcohol and drug abuse. Training in this framework should enhance communication and mutual respect between professionals in different disciplines working to prevent drug abuse. The biopsychosocial approach strengthens risk assessments for prevention programs and improves diagnosis and treatment of individuals likely to be chemically dependent.
It is unlikely that this model represents a clear "paradigm shift", although the postpositivistic and transactional philosophy contributing to this model may eventually have a major impact on theoretical and research paradigms in health sciences and behavioral sciences. The current model is primarily a macro "paradigms integration" framework in which many different theories can be integrated to approximate the complex reality of the etiology of addiction. For these reasons, the biopsychosocial model has much to offer professionals working in research, prevention, and treatment in the addictions field.
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