This conceptualization of a patient’s predicament regards the presenting problem as best understood and treated using a biopsychosocial model of causation (an amplification by George L. Engel of Adolf Meyer’s concept of psychobiology) combined with a systemic view of how these dimensions interact with each other, both within and upon the patient at any point in time.6–8
Dimensions of a predicament. A person functions and experiences his or her sense of self within a multidimensional environment. Mr. M’s predicament embodies numerous dimensions:
- Biological. Pharmacologic interventions intended to contain Mr. M’s distress have helped, but his acute grief and bereavement have merged into a severe major depressive episode.
- Psychological, with counter-dependency. Further exploration reveals that the abrupt loss of his wife unmasked a repressed, lifelong passive-dependency. Until she died, Mr. M had been able to compensate by the sense of control afforded by his profession and his pride in being self-reliant.
- Spiritual. The loss—and anger associated with it—seriously undermined Mr. M’s faith because he felt that “God let my wife die.”
- Interpersonal and social. Mr. M is aware that his wife’s death severed his few connections with her friends and community activities.
- Existential. He feels distressingly alone in an unfriendly world in which he had never felt comfortable.
- Ethnic, familial, economic, cultural, and societal. Mr. M is struggling with the emergence of a life-long sense of inferiority, insecurity, guilt, and self-consciousness related to his immigrant parents’ low socioeconomic status.
I do not believe that medicine and skillful manipulation of central nervous system neurotransmitters can cure this kind of multidimensional, cumulative misery. One is reminded of neo-Freudian Harry Stack Sullivan’s view that “it takes people to make people sick, and it takes people to make people well.”9
CASE CONTINUED: The ‘real work’ begins
Mr. M begins to improve as these factors are elicited and introduced in therapy as dynamic elements of the “field of forces” in which he finds himself struggling. This process essentially detoxifies Mr. M’s misery. He says, “I guess it’s not surprising that I have felt as bad as I have, despite my doctor’s help.”
Insights gained—as well as medication and the psychiatrist’s support and encouragement—are synergistic, and his mood slowly lifts. Mr. M now can begin the difficult work of achieving a more stable sense of security and a closer approximation to his undiscovered “real self” that has eluded him.6 He also is beginning to perceive how his wife’s death has revealed a pre-existing dependency—with persistent fears of abandonment—that left him vulnerable to losses.
Exploring a patient’s predicament is not symptom-focused per se. Some psychiatrists may feel they don’t have time to explore the nature of a patient’s predicament because of managed care constraints or lack of training and experience in using explorative and interpretive psychodynamic techniques. Psychiatrists who employ cognitive-behavioral therapy and related approaches may be uncomfortable or unfamiliar with a biopsychosocial and systems orientation to patient evaluation and treatment that considers the entire context—past and present—in which symptoms emerge.
One could argue, however, that not exploring a patient’s predicament would correspond biomedically to identifying the presence of symptoms (such as anemia, hypertension, a phobia, or orthopnea) but not basing treatment on comprehending their pathophysiology.
Serving the patient’s interests. In psychiatric practice, patients’ interests usually are best served by treatment that is based on understanding their predicaments while refraining from being too distracted by vivid symptoms the components of their predicaments can produce. A biopsychosocial and systemic orientation is clinically useful because:
- The clinician develops a greater connectedness, empathy, and therapeutic leverage from apprehending the field of forces affecting the patient and fashions a treatment plan that takes these forces into consideration. Mr. M’s plan, for example, might include spiritual and financial counseling in addition to conventional treatment for a mood disorder.
- The patient feels the psychiatrist is interested, skilled, and attentive enough to inquire about troublesome areas the patient might or might not have thought were related to his condition.
- The psychiatrist is gratified to see the clinical benefit that can come from recognizing and understanding the patient’s plight when developing a comprehensive treatment plan.
As you gain experience in using this concept, the uniqueness of each person’s predicament will become clear more quickly, even as you encourage the patient to “connect the dots” of his suffering in terms of his personal biopsychosocial history. In doing so, patients will gain a measure of control over situations they had considered overwhelming and mystifying.