The biopsychosocial model is lost in translation: from misrepresentation to an enactive modernization.

The biopsychosocial model (BPSM) is often recommended for musculoskeletal research and practice, but its interpretations and applications vary widely, many deviating from George Engel's original model. This critical narrative review identifies two main versions running in parallel: a humanistic interpretation centered on person- and relationship-centeredness, and a causation interpretation focused on multifactorial contributors to illness. Both have been used in reductionist ways, leading to confusion and suboptimal care. The authors propose an "enactive" modernization that can accommodate both interpretations, aligning with Engel's vision while addressing theoretical limitations and potentially reducing misapplications.

Study at a glance

Abstract

INTRODUCTION: There are increasing recommendations to use the biopsychosocial model (BPSM) as a guide for musculoskeletal research and practice. However, there is a wide range of interpretations and applications of the model, many of which deviate from George Engel's original BPSM. These deviations have led to confusion and suboptimal patient care. OBJECTIVES: 1) To review Engel's original work; 2) outline prominent BPSM interpretations and misapplications in research and practice; and 3) present an "enactive" modernization of the BPSM. METHODS: Critical narrative review in the context of musculoskeletal pain. RESULTS: The BPSM has been biomedicalized, fragmented, and used in reductionist ways. Two useful versions of the BPSM have been running mostly in parallel, rarely converging. The first version is a "humanistic" interpretation based on person- and relationship-centredness. The second version is a "causation" interpretation focused on multifactorial contributors to illness and health. Recently, authors have argued that a modern enactive approach to the BPSM can accommodate both interpretations. CONCLUSION: The BPSM is often conceptualized in narrow ways and only partially implemented in clinical care. We outline how an "enactive-BPS approach" to musculoskeletal care aligns with Engel's vision yet addresses theoretical limitations and may mitigate misapplications.