Bio-Psycho-Social-Spiritual: Completing the Model
Edward J. Cumella, PhD
Research Department
Remuda Programs for Eating Disorders
The Remuda Review: The Christian Journal of Eating Disorders
Fall 2002, Vol 1, Issue 1
Abstract. Health professionals conceptualize illness using a bio-psycho-social model. Recently, health professionals have also embraced the role of spirituality in their conceptualizations. Secular authorities typically reduce spirituality merely to psychological beliefs, emotional experiences, and the social support provided by church attendance. But Christians believe that the spiritual dimension of man exists as a distinct reality. Recent scientific studies on the efficacy of prayer and the health benefits of church attendance suggest the reality of the spiritual dimension. Furthermore, a large quantity of research and theory on the integration of spirituality into mental health has occurred in the Christian tradition. Christian conceptualizations and treatments of mental illness are therefore supported by extensive research.
In 1977, Dr. George Engel developed the “bio-psycho-social model” (Engel, 1977). His model has been adopted by the health professions as the primary model within which to conceptualize and treat both physical and mental illness. The bio-psycho-social model recognizes that mental illness arises from an interactive, dynamic process involving 1) genetic and biomedical factors, 2) psychological, emotional, behavioral, and cognitive factors, and 3) social and family factors. Each area may create a vulnerability to, or protect against, the development of specific mental illnesses. Somewhere among complex bio-psycho-social interactions, mental illnesses arise, progress, heal, or fail to develop at all.
The Spiritual Dimension
In the past decade, the health professions have also embraced the role of spirituality in the development of, recovery from, and protection against mental illness. Renowned psychiatric authorities have published books, and prestigious peer-reviewed journals have offered scientific papers on the importance of spirituality in mental health. Many US medical schools have added courses on spirituality to their standard training (Gundersen, 2000).
The “faculty at Harvard Medical School ... are teaching medical students how to obtain a spiritual history and how to discuss related concerns with their patients.” Americans are also asking for spiritual issues to be addressed in the clinician-patient relationship. Surveys reported by USA Today and Time Magazine indicate that 2/3 of Americans want their health providers to address religion with them. And perhaps as much as 1/2 of Americans want their doctors to pray with them (Gundersen, 2000).
In short, spirituality has found a place in our bio-psychosocial understanding of mental health and illness. Because spiritual beliefs influence thoughts and choices and are often shaped in a social context such as family or church, mainstream sources have come to recognize spirituality as an important aspect of individual psychology and social/family functioning. Spirituality is therefore seen as a key part of the “psycho-social” in the bio-psycho-social model.
But Christians might take a different view of this situation. While agreeing with the role of spirituality in mental health and illness, Christians might disagree with the reduction of spirituality to its mere psychological and social dimensions. Following Biblical teaching, Christians believe that human beings possess a body, a soul, and a spirit. The body clearly corresponds to the “bio” aspect of the bio-psycho-social model. The soul, translated from the New Testament Greek word, psyche, corresponds to the “psycho” aspect of the model. In keeping with this, Scripture informs us that souls consist of emotions, thoughts, and will--all common aspects of modern scientific psychology. Scripture also reflects man’s relational nature. Biblical concepts such as family, congregation, the communal Body of Christ, and national identity all express the social dimension and correspond readily to the “social” aspect of the bio-psycho-social model. But many Christians also believe that human beings have a spirit that is distinct from their soul. Christians assert the existence of an actual spiritual realm and believe that this spiritual reality interacts dynamically with man’s bio-psycho-social makeup. Christians would therefore propose that spirituality cannot be reduced merely to psychological beliefs, emotional experiences, and church socials. Spirituality exists above and beyond these phenomena.
For a Christian, therefore, human beings are bio-psychosocial-spiritual, and only a complete bio-psycho-social-spiritual model will fully address all the dimensions of mental health and illness.
Science and Spirit
Interestingly, focus on the spiritual dimension of man as a distinct reality is not only an article of Christian faith, but also a point with emerging scientific validity. For instance, in recent years there has been an effort to study prayer using scientific methods. Two separate research investigations have found scientifically valid evidence that Christian prayer affects the physical world.
In 1988, Randolph Byrd, MD, published a research paper on prayer in the Southern Medical Journal (Byrd, 1988). His paper followed the scientific method to establish a cause-and-effect relationship. In the study, a computer randomly assigned 393 coronary care patients at San Francisco General Hospital either to be prayed for by a prayer group or not. Since the patients were randomly assigned to prayer or non-prayer conditions, the scientific method allows us to assume that there was nothing inherently different about the patients in the two groups. Furthermore, neither the patients themselves nor anyone rendering treatment at the hospital knew to which group the patients had been assigned. The prayer groups were given only the patients’ first names. These safeguards created a double-blind study: since no one knew who was receiving prayer, no one could treat the prayer patients differently from the non-prayer patients, nor could the prayer patients benefit psychologically from the personal knowledge that someone was praying for them.
In short, we know that both groups of patients had similar medical histories, received the same medical care, and had similar psychological experiences regarding their medical problem. We must therefore attribute any differences in outcome between the prayer and non-prayer patients to the only known difference between them: the prayer that occurred on behalf of those assigned to the prayer groups. No one possessed enough information to inject any other difference into the groups of patients, so no other cause would present itself in the face of differential outcomes.
After ten months, the results indicated that those receiving Christian prayer were five times less likely to need antibiotics, 2-1/2 times less likely to suffer congestive heart failure, and less likely to suffer cardiac arrest.
Such results suggest that Christian prayer effects some kind of healing power. Since no one knew who was being prayed for (except, presumably, God), the differences between the two groups of patients had to derive from prayer itself and could not have arisen from any human intervention. Only prayer distinguished the groups, and therefore the only cause of the health improvement among those who were prayed for would be prayer itself.
In 1999, William Harris, MD, and his colleagues at Mid-America Heart Institute in Kansas City conducted a replication of Dr. Byrd’s 1988 study (Harris, et al., 1999). Harris et al.’s study used very similar methods to Byrd’s, but more patients— 990. In one methodological change, Harris’ cardiac patients did not even know that they were in a study at all, whereas Byrd's patients knew that there was a 50-50 chance that they were receiving prayer.
Harris et al. used a global measure of clinical outcome, and found that patients who received prayer scored 11% lower on the outcome scale. Lower scores mean better outcomes. The result was statistically significant, again suggesting the healing power of Christian prayer.
A second source of scientific evidence for the reality of the spiritual dimension involves recent scientific investigations into church attendance. One study was conducted at Duke University (Koenig, et al., 1999) with 3968 elderly North Carolina residents. The study found that those elderly persons who attended church at least once per week were 46% less likely to die during the six-year period of the study than those who attended church irregularly or not at all. We know that those who attend church are healthier than average due to less alcohol and tobacco use, and that they have more social support than others due to fellowship opportunities in their churches. Therefore, the authors used statistical techniques to tease out these differences—medical illnesses, health practices, social support measures, and demographics. Even when the effects of these factors were removed from the picture, the authors still found that church attendance decreased mortality by 28%.
A similar study tracked 5286 California residents (Strawbridge, Cohen, Shema, & Kaplan, 1997) over a much longer time period, 28 years. This study found a concordant result. People who regularly attended Christian services lived longer than those who did not. Once again, the impact of church attendance persisted even after medical conditions, health practices, and social support were accounted for.
Since it is difficult to fully measure and tease out the effects of health status and social support from the effects of church attendance per se, these studies on church attendance must be seen as less conclusive than the studies on prayer. Nevertheless, the church studies are indeed suggestive and they certainly meet the standards of proof expected of most modern social scientific findings. We cannot therefore dismiss them lightly. Together, they constitute credible evidence for the reality of a spiritual dimension. In conjunction with the demonstrated efficacy of Christian prayer, fair-minded individuals must acknowledge the likelihood that something apparently supernatural seems to exist and is capable of affecting the bio-psycho-social world.
Harold Koenig, MD, associate professor at Duke University Medical School, summarizes the situation thus: “On scientific grounds there is good evidence, in my view, that religious commitment... is associated with better health. And then there’s the tantalizing idea that there’s something beyond the social support, beyond the lifestyle and the meditation. Scientifically, you would say that’s something that we can’t explain. A person of faith would say that’s the hand of God” (quoted in Gundersen, 2000).
Clearly, then, modern science is arriving at the same view of human beings that the Bible has offered for thousands of years. The Bible through direct revelation, and science through an accurate study of the world God made, are both converging on a bio-psycho-social-spiritual understanding of human beings. Even for a purely secular practitioner who may not accept the reality of a spiritual realm and who may explain the impact of spirituality in purely psycho-social terms, it is nevertheless clear that spirituality matters and plays a role in the understanding, treatment, and prevention of mental illness.
Christian Integration
In this light, it becomes important to consider how to incorporate spirituality into our work with mentally ill people.
The prevailing view of mainstream authorities who promulgate the role of spirituality is that any spiritual tradition can be incorporated with equal effectiveness into treatment. And, of course, all mental health practitioners would agree that it is essential to respect and to work within patients’ existing spiritual beliefs. However, of the many spiritual traditions, by far the greatest quantity of research and theory on the integration of spirituality into mental health has occurred in the Christian tradition.
The field of integration studies endeavors to integrate counseling and Christianity into a unified conceptual and treatment model. Accredited universities and seminaries support this work, as do scientific journals dedicated exclusively or predominantly to this work, such as The Journal of Psychology and Christianity and The Journal of Psychology and Theology. Thousands of books have been written on the topic of recovery and healing from a Christian perspective. Therefore, the mental health professional wishing to follow the standards of the field and incorporate spirituality into his or her research or clinical work can draw on an extensive literature and evidenced-based content regarding the integration of patient care and Christianity. For other spiritual traditions, this wealth of resources is not available.
This leads us to a key point: Christian-based mental health programs are not only following the standards of current practice by integrating spirituality into treatment, but they are also doing so in perhaps the most scientifically-defensible and valid manner possible given the present state of knowledge.
In sum, Christian conceptualizations and treatments of mental illness are supported by extensive research. It is from this perspective that The Remuda Review intends to delineate and disseminate a Biblically-based, Christ-centered understanding of the etiology, assessment, and treatment of a specific class of mental illness--eating disorders.
Remuda seeks in its work and through this journal to apply the current scientifically-valid and Biblically-based understandings of mental illness to the specific problems of anorexia, bulimia, and related disorders. In so doing, we follow the currents of mental health practice and the standards of evidenced-based treatment, and we honor a Christ-centered, Biblical tradition.
We have presented in this article a brief summary of the scientific validity of Christ-centered treatment. In the companion article, Five Biblical Factors in Eating Disorder Development, we establish a Biblical basis for scientifically-developed mental health concepts and interventions. The two perspectives harmonize and support each other, both converging on a truly holistic approach to understanding and treating persons with mental illness: a bio-psycho-social-spiritual model.
References
Byrd, R.C. (1988). Positive therapeutic effects of intercessory prayer in a coronary care unit population. Southern Medical Journal, 81, 826-829.
Engel, G.L. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196, 129-136.
Gundersen, L. (2000). Faith and healing. Annals of Internal Medicine, 132, 169-172.
Harris, W. S., Gowda, M., Kolb, J.W., Strychacz, C.P., Vacek, J.L., & Jones, P.G.. (1999). A randomized, controlled trial of the effects of remote, intercessory prayer on outcomes in patients admitted to the coronary care unit. Archives of Internal Medicine, 159, 2273-2278.
Koenig, H.G., Hays, J.C., Larson, D.B., George, L.K., Cohen, H.J., & McCullough, M.E.. (1999). Does religious attendance prolong survival? The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 54, M370-376.
Strawbridge, W.J., Cohen, R.D., Shema, S.J., & Kaplan, G.A. (1997). Frequent attendance at religious services and mortality over 28 years. American Journal of Public Health, 87, 957-961.
