A SOCIOPSYCHOBIO MODEL of HEALTH Group Life Shapes the Psychology and Biol

Haslam S. Alexander (Orcid ID: 0000-0001-9523-7921)

A SOCIOPSYCHOBIO MODEL OF HEALTH 34

Running Head: A SOCIOPSYCHOBIO MODEL OF HEALTH

Group life shapes the psychology and biology of health: The case for a sociopsychobio model

S. Alexander Haslam1, Catherine Haslam1, Jolanda Jetten1,

Tegan Cruwys2, & Sarah Bentley1

1 The University of Queensland

2 The Australian National University

submitted to Social Psychology and Personality Compass

Address for correspondence: Alex Haslam, School of Psychology, The University of

Queensland, Brisbane, QLD 4072, Australia. e-mail: [email protected]; tel.: (+61)

(0)7 3346 7345

This is the author manuscript accepted for publication and has undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/spc3.12490

Acknowledgement: Work on this paper was supported by grants from the Australian

Research Council (FL110100199 & DE160100592). The authors would like to thank

Blair Johnson and Alex Rothman for helpful feedback on earlier drafts of this

manuscript.

Abstract

Engel (1977) presented a compelling case for a biopsychosocial model of health as a

challenge to a biomedical model that he saw as reductionistic, physicalistic and exclusionist.

Yet despite its laudable goals and popularity, the biopsychosocial model can be faulted for

being incremental, imprecise, and individualistic. Ultimately, this means it is no less

reductionist than the biomedical model which it sought to supplant. In this paper, we present

a reformulation of this model that foregrounds the capacity for social groups—and the social

contexts in which those groups are embedded—to structure psychology and, through this,

biology and health. This sociopsychobio model argues that the three elements of Engel’s

framework are not fixed and immutable, but rather dynamic and interdependent. The model

is consistent with a range of recent approaches to health that have focused on the important

role that social class, social inequality, social structure and social networks play in shaping health outcomes. In this paper, though, the concrete value of this reformulation is illustrated through a discussion of recent research that focuses on the role of group memberships and associated social identities in shaping the psychology and biology of stress. This review underlines two key points that are central to the general case for a sociopsychobio model of health. First, that groups are a force in the world that shape the psychology and biology of their members (as well as members of other groups) in ways that cannot be reduced to those

group members’ functioning as individuals. Second, that groups provide their members with

a basis for seeking to change the world rather than simply accepting it. In this, group life is

not merely an appendage to psychology and biology, but is instead a basis for collective

experiences that have the potential to unleash new expressions of both.

Key words: social identity, biopsychosocial model, health, metatheory, behavioural medicine

Group life shapes the psychology and biology of health: The case for a sociopsychobio model

The biopsychosocial model of health: Incrementalism, imprecision, and individualism

As Engel (1977) observed in his ground-breaking review of the field, the biomedical

model that has dominated the health sciences for the last two centuries “has been successful

beyond all expectations” with “a firm base in the biological sciences, enormous technological

resources at its command, and a record of astonishing achievement in elucidating mechanisms of disease and devising new treatments” (pp.129, 131). Famously, though, Engel came to bury the biomedical model rather than to praise it. In particular, he noted that while a

model which focuses on disease and the breakdown of biological and physiological

functioning provides clear guidelines for health management (particularly in the case of

infectious diseases), it has limited relevance in a world where the prevailing causes of ill-

health are chronic conditions for which there is no straightforward medical ‘fix’ (e.g.,

diabetes, depression, cardiovascular disease). He went on to argue that its “reductionistic”,

“physicalistic” and “exclusionist” framework was neglectful of both the human condition and the lived experience of disease (1977, p.129).

To be fit for purpose, Engel argued that biological and physiological analysis needed to be supplemented with an awareness of the way in which “human” factors contribute to both the trajectory and the experience of illness (see also Deacon, 2013; Hewa &

Hetherington, 1995; McInerney, 2018). More particularly, he made the case for a biopsychosocial model which recognises biological influences, but that is also inclusive of those social and psychological elements for which the biomedical model has no place.

Yet at the same time that he laid out the groundwork for this new model, Engel

recognised that it would not be easy for it to gain acceptance, given the dominance of the

biomedical model and its dogma. Given this, it is perhaps surprising how much progress has

been made by those who have followed in Engel’s footsteps. Indeed, for many researchers

and practitioners today the biopsychosocial model is the health model of choice (McInerney,

2018; Lehman, David, & Gruber, 2017; Suls & Rothman, 2004). This is particularly true for

allied health professionals whose focus is on the psychiatric and psychological conditions

with which Engel was primarily concerned (e.g., stress, depression, addiction, eating

disorders; for a recent review see Haslam, Jetten, Cruwys, Dingle, & Haslam, 2018a).

Nevertheless, for all the progress that has been made, the biopsychosocial model still

has at least three significant shortcomings. First, while Engel envisaged an approach that

gives equal weight to the biological, psychological and social dimensions of health, many

researchers have argued that the biopsychosocial model is still dominated by the ‘bio’

(Epstein, 1992; Suls, Luger, & Martin, 2010). The result is that social and psychological

elements tend to be ‘tacked on’ incrementally to biomedical models rather than properly

integrated within them (Benning, 2015). Indeed, Ghaemi (2011) argues that incrementalism

— in which social and psychological elements are treated as supplements to a biological core

— has ultimately served only to entrench the dogma of the biomedical model (see also

Pilgrim, 2002). Consistent with this point, it is apparent that public perceptions of health are

still dominated by a medical imagination in which physical determinants are seen as far more

important than social ones — even where this flies in the face of clear empirical evidence to

the contrary (Haslam et al., 2018b).

Second, the biopsychosocial model is unclear about how precisely the social and

psychological elements interact with biological elements in health contexts to influence

outcomes (Havelka, Despot Lucanin, & Lucanin, 2009; Lehman et al., 2017). Amongst other

things, this imprecision means that the model is often understood to offer a list of eclectic and

vague “ingredients” that affect health, rather than to integrate these within a coherent and

well-specified theory (Suls & Rothman, 2004). As well as making the model hard to test

empirically (McLaren, 1998), this additive framework fails to appreciate that all three elements of the model can structure one another. In particular, researchers routinely neglect

the capacity for people’s biology and psychology to be shaped by the groups to which they

belong and the social contexts in which those groups are embedded (Caporeal & Brewer,

1995; Ghaemi, 2011). More generally, the biopsychosocial model can be seen to present, at

best, a model of mechanical interaction in which biological processes are moderated by

psychological and social factors rather than a model of dynamic interaction in which the

elements have the capacity to fundamentally transform each other (Reynolds & Branscombe,

2015).

Third, it is nevertheless the case that as research informed by the biopsychosocial

model has progressed, it has explored the psychological (i.e., cognitive and emotional)

dimensions of health in ways that provide a strong and compelling evidence base pertaining

to a wide range of conditions (e.g., Beck, 2011; Ehlers & Clark, 2000; Harvey, 2004). Yet the

individualistic framing of this work means that here again the social dimensions of health are typically relegated to the theoretical suburbs. For example, in cognitive behaviour therapy

(CBT), the analytical gaze is largely on the cognitions of the individual client rather than on

the social contextual factors which feed into and modify those cognitions (Cruwys et al.,

2014). Amongst other things, this means that when CBT or other therapies are conducted in

groups or in conjunction with other more ‘social’ therapies (e.g., Hollon et al., 2005), the

group is often seen as a context for individual psychology to play out rather than as

something that might transform that psychology (Cruwys, Haslam, Fox, & McMahon, 2015).

This is evident in the common practice of transplanting interventions developed for

individuals into group contexts, with little or no awareness of the capacity for the group

processes that this unleashes to qualitatively transform the psychology of participants (Khan,

Tarrant, & Farrow, 2016). Relatedly, psychological models generally focus on the

psychology of the individual as an individual and see this as largely impervious to social

influences. Yet in failing to appreciate how psychology can be fundamentally (re)structured

by society these various instantiations of the biopsychosocial model are open to the charge

(psychologization).

However, despite these shortcomings, it is apparent that the biopsychosocial model continues to have widespread appeal. One reason for this is that the individualistic conceptualisation at its heart itself draws on a powerful ‘folk model’ that reflects a political imagining of psychology that is widely embraced in Western societies (Pepitone, 1981;

Turner & Oakes, 1986). So while many researchers and practitioners would readily acknowledge the influence of groups and communities on health, they are inclined to see these as factors that are ‘out there’, rather than as things that are ‘in here’ as an aspect of a person’s core psychology. Accordingly, when it is represented schematically the biopsychosocial model is typically presented either as a set of overlapping (but fixed and tightly defined) circles or as a series of concentric rings (with biological elements at the centre, and the social influences at the periphery; see Figure 1).

— Insert Figure 1 about here —

But are these elements really so immutable and independent? And, if they are not, might Engel’s ambitions be furthered by a reframing which emphasises the capacity for group life to transform both psychology and biology? In what follows, we use social identity theorizing to provide a framework for answering these questions in ways that make the case for an alternative sociopsychobio model of health. Our reasoning here is grounded in awareness of the capacity for group life to structure psychology (Tajfel, 1972; Tajfel &

Turner, 1979; Turner & Oakes, 1986), biology (Sapolsky, 2017) and thereby health (Haslam,

Jetten, Postmes, & Haslam, 2009; Haslam et al., 2018b; Jetten, Haslam, & Haslam, 2012).

Importantly, this alternative model is consistent not only with social identity research but also with the broad sweep of recent research that has made a compelling case for the role of

group-based factors in shaping health outcomes (e.g., those pertaining to social class, social

capital, social networks, and social support; e.g., Johnson & Acabchuk, 2018; Marmot, 2015;

Timmermans & Tietbohl, 2017; Wilkinson & Pickett, 2010).

Social identity and health

The starting point for the social identity approach to health is to argue that social groups are not simply ‘out there’ in the world, but can also shape, and be incorporated into individual psychology as a central aspect of a person’s sense of self. Certainly, we can define

and understand ourselves as individuals, in terms of idiosyncratic features that define our

personal identity as unique and distinct from others (Turner, 1982). However, in a range of

social contexts we also understand ourselves, and behave, as members of groups whose

feelings and cognitions reflect a social identity that is shared and shaped by fellow ingroup

members (Tajfel, 1972). In this regard, a starting point for social identity theorizing is to take

these collective manifestations of self seriously by recognizing the psychological reality of

the group (Turner & Oakes, 1986; Turner, Hogg, Oakes, Reicher, & Wetherell, 1987). This

means that far from being of only peripheral relevance, social identities can be seen to be a

driving force in most aspects of our lives — at home (e.g., as members of family groups;

Wakefield, Sani, Herrera, & Zeybek, 2017), at work (e.g., as members of work teams and

organisations; Haslam, 2004), and in society at large (e.g., as members of recreational groups,

political parties, or sports clubs; Wann & Branscombe, 1990). At the same time, people’s

sense of self is also routinely structured by their membership of large-scale social categories

(e.g., those based on gender, nationality, ethnicity, and social class; Turner, Oakes, Haslam,

& McGarty, 1994).

In all these contexts social identities furnish people with a powerful sense of self (e.g., as “us Smiths”, “us psychologists”, “us migrants”). As specified within self-categorization theory (Turner et al., 1987, 1994), the internalisation of social identity also serves to structure psychology in ways that make group behaviour possible (Turner, 1982). Most particularly, they do this by (a) creating a sense of similarity and connection to other ingroup members (a sense that “we are in the same boat”; Oakes, Haslam & Turner, 1994) and thereby (b) providing a platform for mutual influence and co-ordination which brings the thoughts and

actions of those ingroup members into alignment (Haslam, 2004; Turner, 1991).

In explaining how structural features of the social world ‘get under the skin’, these

ideas have a range of profound implications for health (Taylor et al., 1997). Amongst other

things, this is because perceiving oneself to share social identity with others is a basis for a

sense of (a) trust and support (Haslam, Reicher & Levine, 2011), (b) self-esteem (Jetten et al.,

2015), (c) control, agency, and efficacy (Greenaway et al., 2015; Howell et al., 2014;

Muldoon et al., 2017), and (d) purpose, direction, and meaning (Cruwys, Haslam, Dingle,

Haslam, & Jetten, 2014; Drury & Winter, 2004; Oyserman et al., 2017). Importantly, over the

course of the last decade each of these observations has been confirmed by a large body of

empirical evidence obtained from diverse populations, in multiple domains, and across a

range of clinical conditions and contexts (for a comprehensive review, see Haslam et al.,

2018a).

At a more fundamental level we would argue that the importance of social identity for

health derives from the fact that humans are social animals who live, and have evolved to

live, in social groups (e.g., Dunbar, 1998, 2013). As Turner and Oakes (1986, p.239) observe

“society is the natural form of being of human individuals … there is no such thing as the pre-social, asocial, or purely biological ‘as if isolated’ individual, except as an analytic abstracted fiction”. Moreover, because it is social identity that makes group behaviour possible, it follows that it is this that allows people to fulfil their potential as inherently social beings. By the same token, though, if the capacity to act in terms of shared identity is compromised (e.g., through loss of group memberships following trauma, retrenchment, emigration, poverty, and disability) then this will constitute a major threat to social, psychological, and also biological functioning. This observation is consistent with growing evidence of the devastating psychological and physical health implications of loneliness and

social isolation (e.g., Cacioppo & Patrick, 2008; Holt-Lunstad, Smith, & Layton, 2010;

Johnson & Acabchuk, 2018; Lim, Rodebaugh, Zyphur, & Gleeson, 2016) — something that can be conceptualised as reflecting a chronic lack or loss of social identification. Again, this is a claim that is supported by a large and growing body of research (e.g., Cruwys et al.,

2013; Greenaway, Cruwys, Haslam, & Jetten, 2016; Matheson, McQuaid, & Anisman, 2016;

Steffens, Cruwys, Haslam, Jetten, & Haslam, 2016; Steffens, Haslam, Schuh, Jetten, & van

Dick, 2017).

Social identity and the case for a sociopsychobio model of health

The significance of the foregoing arguments for our present discussion is that they

point to a key weakness in the biopsychosocial model of health. This arises from the fact that

This article is protected by copyright. All rights reserved. A SOCIOPSYCHOBIO MODEL OF HEALTH 11 the metatheoretical framing it provides (or is understood to provide) does not allow for a full and proper appreciation of the importance of social processes in shaping health outcomes

(Suls & Rothman, 2004). In particular, as we have seen, this is because by giving theoretical and practical primacy to the biological over the psychological and to the psychological over the social, group processes are relegated to the model’s margins, and seen as providing a backdrop to matters of health, rather than as being in any sense foundational (Lyons &

Chamberlain, 2017).

In contrast, as suggested above, we follow Turner and Oakes (1986, p.239) in arguing for an approach which embraces the idea of a “reciprocal (dialectical) interaction and functional interdependence between the [biological and] psychological processes of individuals and their activity, relations, and products as society”. In these terms, there is no sense in which any one particular aspect (or analysis) of human behaviour (i.e., biological, psychological or social) is any more fundamental or ‘core’ than any other. On the contrary, our humanness is — and needs to be understood as — the product of their ongoing interaction. Nevertheless, putting the social at the forefront of our considerations (and at the front of our model’s name) signals a pressing need to do more than merely pay lip service to the importance of group life and associated social processes for health.

But does this really matter? Well, yes it does. Indeed, one very practical consequence of failing to appreciate the health-relevant power of social groups is that their potential to be a source of cure (as well as harm) is routinely overlooked. Perhaps the clearest evidence of this is found in reports of the value of group-based health interventions that involve such things as exercise, dance, music, reminiscence, and even water consumption. In the majority

of these cases, practitioners choose to deliver the interventions in a group format for

pragmatic rather than theoretical reasons (i.e., because it is more time- and cost-effective, rather than more effective per se). Moreover, where group interventions produce positive outcomes (as they often do), this is almost always explained in terms of their content (e.g., the exercise, the dance, the music, the reminiscence, the water) and hardly ever in terms of the group through which that content is delivered. Conceptualisations of group treatment also focus almost exclusively on individual-level processes rather than seeing the group itself either as having higher-order health-relevant properties, or as an active ingredient that makes a distinctive psychological contribution to outcomes (e.g., Cruwys et al., 2015; Karney et al.,

2010; Khan et al., 2016; McMahon et al., 2017; Tarrant, Haslam, Carter, Calitri, & Haslam, in press).

When efforts are made to tease these elements out experimentally, it is also apparent that as well as explaining a non-trivial amount of variance in outcomes, the group is often essential to getting any positive outcomes at all (e.g., see Gleibs, Haslam, Haslam, & Jones,

2011; Haslam et al., 2010). Again, blindness to such a possibility can be seen to reflect the pervasiveness of the dominant ‘folk model’ of health in which the individual qua individual is sovereign and no significance is attached to the exigencies and sequelae of group life.

As a corrective to this ‘folk model’ (which, if not dogma, is at least a pervasive unconscious bias), we argue that Engel’s (1977) framework would benefit from being recast

as a sociopsychobio model of health. This reformulation provides an affirmative linguistic

framing in which social elements are positioned as primary drivers of health processes rather

than as third-class passengers. This not only foregrounds social influences on health but also

flags their routinely overlooked capacity to structure health outcomes in both positive and

negative ways.

Importantly, this sociopsychobio model still embraces Engel’s (1977) original, and in our view correct, vision for a balanced approach to health in which no single dimension—

biological, psychological or social—is privileged to the exclusion of others. Nevertheless, by

understanding all three dimensions to be dynamically interdependent so that each has the

capacity to structure the other two (e.g., in ways suggested by Anisman, 2016; Lehman et al.,

2017; Sapolsky, 2017; Stewart, Rand, Muldoon, & Kamarck, 2009; see Figure 2), the model

seeks to challenge the particularly problematic forms of reductionism that stem from seeing

the model’s social elements as ground rather than figure and as caboose rather than engine.

—Insert Figure 2 about here —

The benefits of a sociopsychobio model of health: Precision, social interactionism, and

transformation

But does it make any practical difference for the professional activity of health

researchers and practitioners to be informed by a sociopsychobio model rather than by a

biopsychosocial one? To address this question, and by way of example, we provide a short

review of recent research on the topic of stress which has explored hypotheses derived from

theorising on social identity and health (after Haslam et al., 2009). In particular, we use this

review to examine the capacity for a sociopsychobio approach to be (a) precise (rather than

imprecise), (b) socially interactionist (rather than individualistic), and (c) transformational

(rather than merely incremental).

Importantly, it needs to be recognized that the topic of stress is one of many that we

might have chosen for this purpose. This is because in recent years, as with other work on

social determinants of health (e.g., Wilkinson, & Marmot, 2003), social identity theorizing

has been used as a basis for reframing our understanding of a broad range of health

conditions — from depression and ageing, to eating disorders and addiction (see Haslam et

al., 2018a; Jetten et al., 2012, for reviews). In these and other contexts it has also paid

particular attention to the way in which health experiences and outcomes are shaped by the

status of a person’s group memberships (Begeny & Huo, 2018; Sani, Magrin, Scrignaro, &

McCollum, 2010) and by the stigma and discrimination that often accompany membership in low-status groups (e.g., associated with age, class, gender, disability, ethnicity; Branscombe,

Schmitt, & Harvey, 1999; Goodman et al., 2017; Jetten, Haslam, Cruwys, & Branscombe,

2018; Major, Quinton, & McCoy, 2002; Penner, Blair, Albrecht, & Dovidio, 2014).

Nevertheless, examination of how thinking about stress has evolved over the last century

provides a useful way of illustrating not only how the biopsychosocial model has advanced our understanding of health but also of how, by failing to properly appreciate the capacity for

group life to structure psychology and biology, it has ultimately held that understanding back.

The example of stress

For much of the last century, theorizing about stress was dominated by a biomedical

model which took the view that, as they are exposed to increasing strain, people’s

physiological stress responses go through a defined series of stages. In particular, Selye’s

(1946, 1956) work on the general adaptation syndrome argued that these responses have

three distinct phases: the registering of threat in the form of alarm which then triggers a state

This article is protected by copyright. All rights reserved. A SOCIOPSYCHOBIO MODEL OF HEALTH 15 of heightened arousal in the form of countershock, and which—depending on how successfully a person deploys their adaptation energy—then leads either to resistance or exhaustion.

Despite the fact that Selye’s work did much to capture the biological processes implicated in stress responses (see Jackson, 2012, 2013, for reviews), it is clearly the case that there is a role for psychological and social processes in the trajectories he mapped out. In particular, this is a point that is powerfully demonstrated in research informed by Lazarus and

Folkman’s (1984; Lazarus, 1996) transactional model of stress. This argues that a person’s appraisal of stressors as harmful (primary appraisal) and of their ability to cope with those stressors (secondary appraisal) both play a critical role in determining whether or not people succumb to the potentially debilitating consequences of stress. Extending this analysis, recent work by Crum and her colleagues shows that stress responses are predicted by stress mindsets which lead perceivers to see stress as either enhancing or debilitating (Crum, Salovey, &

Achor). In line with Engel’s metatheory, within this body of work cognitions are understood to be structured not only by a person’s assessment of their coping resources but also by the social context in which these arise (e.g., so that some contexts are recognised as affording more opportunities for positive cognitions than others). Amongst other things, this suggests that interventions which target these appraisals and mindsets (e.g., as part of CBT or job training) can be an effective form of stress treatment (e.g., see Butler, Chapman, Forman, &

Beck, 2006; Crum & Langer, 2007).

Nevertheless, for all the progress that this work entails, as Folkman and Moskovitz

(2004, p.758) acknowledge, it is limited by the individualistic metatheory that it shares with

Selye’s earlier work. Most particularly, this means that the role of group processes in

transforming psychology (and, through this, biology) is largely overlooked. This is something

which social identity theorizing seeks to correct by pointing to the ways in which cognition is

fundamentally and powerfully structured by shared group memberships (Turner et al., 1994).

In the case of primary appraisal, then, this can be seen to be deeply conditioned by

people’s group memberships and their identification with those groups — so that appraisal is

framed not just by personal identity (“Is this a threat to me?”) but by social identities (e.g.,

“Is this a threat to us?) and also depends on the nature of those social identities (i.e., who

“us” is). In line with this idea, research by Levine and colleagues has shown that the perceived seriousness of a particular stressor (e.g., a knee injury vs. a facial scar) varies substantially as a function of the salient social identity of a perceiver (e.g., whether a sportswoman sees herself as an athlete or as female; Levine & Reicher, 1996).

As well as simply being subjective, stress appraisal can thus be seen as intersubjective in so far as it is structured by social identities that are shared (to varying degrees) with others.

Two further consequences of this are that appraisal (a) is structured by the appraisals of other people (e.g., colleagues, therapists, experimenters), but also (b) depends on who those people are (in ways that also accord with the principles of a Network-Individual-Resource Model

(NIRM; Johnson et al., 2010). Consistent with this proposition, research has shown, for example, that perceivers’ stress appraisals are influenced more by the views of fellow ingroup members (e.g., for women other women, for students other students) than by those of

outgroup members (Haslam, Jetten, O’Brien, & Jacobs, 2004; Häusser, Kattenstroth, van

Dick, & Mojzisch, 2012; Platow et al., 2007). Moreover, it is apparent that ingroup members

play a particularly important role in transforming stress appraisals and mindsets, so that, for

example, things which might seem threatening to a person as an individual (e.g., having to

diffuse a bomb, surviving in freezing temperatures) become normalized — and even relished

— through group activity (e.g., as a bomb disposal officer, as an arctic explorer; Haslam,

O’Brien, Jetten, Vormedal & Penna, 2005; Suedfeld, 1997).

Beyond this, social identity processes also play a critical role in the nature and impact

of secondary appraisals of stress. In particular, this is because perceptions of social support

— which are a major determinant of a person’s perceived capacity to cope with particular

stressors — are heavily structured by shared social identity (for a review see Haslam, Reicher

& Levine, 2012). This is for two key reasons. First, support is typically given more to those

who are perceived to be members of an ingroup than to those who are members of outgroups

(Levine, Prosser, Evans, & Reicher, 2005; Levine & Thompson, 2004). Second, when

support is received, the extent to which it is seen to be helpful also depends upon whether it is

provided by ingroup or by outgroup members. Amongst many other things, this means that

whether or not a person “takes their medicine” (and hence whether that medicine impacts on

their biology) depends critically on who is giving it to them (Fenton, Blyler, & Heinssen,

1997; Zeber et al., 2008). Indeed, more generally, this explains why the therapeutic alliance

— which can be understood as the product of an emergent sense of shared social

identification between therapist and client — is such an important determinant of therapeutic

outcomes (Horvath & Symonds, 1991).

Importantly too for our present argument, identity-based differences in appraisal have also been shown to have profound effects on physiology. For example, Häusser and

This article is protected by copyright. All rights reserved. A SOCIOPSYCHOBIO MODEL OF HEALTH 18 colleagues (2012) found that when students had to perform a stressful public-speaking exercise their cortisol levels were significantly lower — indicative of a lower level of stress

— if their social (rather than personal) identity had previously been made salient via a task that reinforced their connection to fellow students (see also Ketturat et al., 2015). Likewise,

Platow and colleagues (2007) found that physiological responses to pain were only attenuated by reassurance if this was provided by an ingroup member (a student from the same rather than a different discipline). Relatedly, where stressors are chronic, meaningful group life has been shown to have the capacity to buffer people from their long-term deleterious effects on immune system functioning (Anisman, Hayley, & Kusnecov, 2016; Cole, Kemeny, & Taylor,

1997; Johnson et al., 2010).

Significantly, these various processes do not simply change people’s cognitions — and through this their physiology and biology — but also have the capacity to transform the world which gives rise to particular stressors. In this regard, one pertinent critique of dominant psychological models is that they take the social world, and the stressors it produces, as a given rather than as something that can be contested and changed. This is seen particularly clearly in workplace policies which aim largely to help employees cope with, and adjust to, the stressful demands and challenges they face (rather than to push back against them; Abramovitz & Zelnick, 2010). Whether or not employees are able to do this has been shown to be shaped by their sense of shared social identity and the sense of solidarity, connection and self-efficacy this affords (Steffens et al., 2017). Yet at the same time this social identity-based solidarity can also be a basis for people to work together to remove some of the stressors by which they might be harmed in ways that they cannot do on their

own (Cameron et al., 2018; Crabtree et al., 2010). This suggests that intervention should not always be individuated and personalised in ways that focus on changing the individual, but should sometimes be collective and politicised in ways that focus on changing the system in which particular groups are embedded (e.g., in ways suggested by critical health psychologists; e.g., Cwikel, 2006; Zoller, 2005).

Figure 3 provides a schematic representation of these various processes. Evidence of

their simultaneous action was also provided by Reicher and Haslam (2006) in research which

examined the social and health dynamics of two groups (Prisoners and Guards) in a simulated

prison. On the one hand, as Prisoners came together as a group, they not only became

healthier and less stressed (in ways that had a measurable effect on their physiological

functioning) but were ultimately able to work together to overthrow the regime which was

the source of their stress (Haslam & Reicher, 2006). On the other hand, though, the Prisoners’

actions also had profound implications for the Guards who were charged with maintaining

that regime — who, as their group came under assault, became more stressed, paranoid, and

depressed (Reicher & Haslam, 2006). Significantly too, there was nothing in participants’ prior psychology or biology that predicted these outcomes, since all had been pre-screened as healthy, well-adjusted and resilient.

— Insert Figure 3 about here —

In lending support to hypotheses derived from social identity theorising, these various strands of empirical work on stress serve to underline two key points that are central to the general case for a sociopsychobio model. The first is that groups are a force in the world that shape the psychology and biology of their members (as well as members of other groups) in

ways that cannot be reduced to those group members’ functioning as individuals. At a

biological level, this point is reinforced by a wealth of research in developing fields at the

intersection of social science and medicine (e.g., epigenetics and socioendocrinology). Such

work has shown, for example, how the deprivation experienced by slaves led to genetic

selection of the ability to conserve salt (Cacioppo, Berntson, Sheridan, & McClintock, 2000) and how exclusion from valued group memberships (e.g., in the form of ostracism) can both up-regulate and down-regulate physiology (McGuire & Raleigh, 1986). It has also explored

how the physiology and neurobiology of immigrants and Indigenous peoples is shaped by the

treatment they receive at the hands of majority groups in society (Bombay, Matheson, &

Anisman, 2014; Matheson & Anisman, 2012) and how teachers who experience burnout

create stress-related biological changes in their students (Oberle & Schonert-Reichl, 2016).

The second point is that groups provide their members with a basis for changing the

world rather than simply accepting it. Rather, then, than only ever being an appendage to

psychology and biology, we see that group life is a basis for collective experiences that have

the potential to unleash new expressions of both. One rather obvious point, for example, is

that whether or not a person goes to war — and hence has their mind and body dramatically

changed by this experience — is not something they do on their own, but rather only happens

because they belong (and see themselves as belonging) to a particular social group (Muldoon

& Downes, 2007). At a more everyday level, it is also apparent that people’s membership of

particular groups (e.g., ones with high socio-economic status) has a very significant bearing

on their exposure to privation, violence and disease, and on their access to medicine and

healthcare (Goodman et al., 2017). In all these cases, groups are therefore not just contexts in

which psychological and biological processes are played out, but the reason why particular

psychologies and biologies prevail (Sapolsky, 2017).

Conclusion

The goal of this paper has been to breathe fresh life into the biopsychosocial model of

health by reimagining it in ways that take the social components of Engel’s triptych more

seriously, while also making a case for the dynamic interplay of social, psychological and

biological factors in the determination of health. At one level, this can be construed simply as

a corrective to a model in which the social is perennially treated, at the wedding of

disciplines, not as a valued family member but as a poor relation consigned to an outer table.

In this sense our contribution aligns with recent calls to “burst the biomedical bubble” by

taking the social (alongside behavioural and environmental) determinants of health more

seriously (Jones & Wilsdon, 2018; The Lancet, 2018, p.187). Our ambition, though, is greater

than this—in aiming to show how, by properly appreciating the social, we can at the same

time also enrich our understanding of the psychological and the biological. In this sense, we

are bursting the bubble only to reimagine it in a more sustainable form.

In concluding, it is important to stress that the sociopsychobio model we have

outlined is not simply (meta)theoretical. Moreover, although we have used the social identity

approach as a means of explicating this new model, this is not the only theoretical framework

that is, or could be, consistent with its tenets. For example, the model accords with key

elements of the Network-Individual-Resource Model (Johnson et al., 2010) and Dislocation

Theory (Alexander, 2008) as well as with the vast literature on social determinants of health

(Berkman & Syme, 1979; Marmot, 2015; Putnam, 2000; Wilkinson & Pickett, 2010). In this

way, as the stress research that we have reviewed shows quite clearly, it offers a broad-based

“blueprint for research, a framework for teaching, and a design for action in the real world of health care” (Engel, 1977, p.135). In this too, our ultimate goal is not to malign the author of these words but instead to render his vision both more concrete and more achievable.

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