“Biopsychosocial” Model in Health Psychology: Towards an Integrated Approach and a Critique of Cultural Conceptions

Open Journal of Medical Psychology, 2012, 1, 51-62 http://dx.doi.org/10.4236/ojmp.2012.14009 Published Online October 2012 (http://www.SciRP.org/journal/ojmp)

The Status of the “Biopsychosocial” Model in Health Psychology: Towards an Integrated Approach and a Critique of Cultural Conceptions

Andrew R. Hatala Department of Psychology, University of Saskatchewan, Saskatoon, Canada Email: [email protected]

Received July 10, 2012; revised August 20, 2012; accepted September 13, 2012

ABSTRACT The current status of the “Biopsychosocial” Model in health psychology is contested and arguably exists in a stage of infancy. Despite original goals, medical researchers have developed theoretical and empirical integrations across bio-psycho-social domains only to a limited extent. This review article addresses this issue by making connections across research findings in health psychology and related medical fields in order to strengthen the associations across bio-psycho-social domains. In particular, research in sociosomatics, neuroplasticity and psychosocial genomics are introduced and explored. The role of “culture” as conceived of within the Biopsychosocial Model is also ambiguous and somewhat problematic. Arthur Klienman’s conceptions of culture as what is at stake for individuals in their local social and moral worlds is adopted to offer a critique of previous perspectives of culture and question its role amidst bio-psycho-social domains. Overall, a multilevel integrative or “holistic” perspective is advanced to strengthen the Bi- opsychosocial Model for use within health psychology and biomedical research. In the end, some clinical implications are discussed.

Keywords: Biopsychosocial Model; Health Psychology; Culture; Sociomatics; Psychosocial Genomics

1. Introduction disorders and the pathogenesis of physical ailments such as cardiovascular disease (clinical health psychology) Health psychology emerged as a distinct subfield of [6,7]; effective health intervention, promotion and pre- psychology when the American Psychological Associa- vention of disease and illness in schools, work sites and tion’s (APA) Task Force on Health Research was com- “daily living” (public health psychology) [8,9]; commu- missioned in 1976 to address concerns over increasing nity health justice and social action (community health rates of “preventable” diseases in the United States [1]. psychology) [10-13]; the identification and comparison During a fifty year span between 1920 and 1970, the of major etiological agents of illness in a variety of cul- prevalence of acute infectious diseases like influenza, tures (cultural health psychology) [14,15]; critiques of measles, and tuberculosis declined in the North America mainstream “Western” approaches to and understandings while what have been termed “preventable” conditions of health and illness (critical health psychology) [16-19]; have substantially increased, including cardiovascular psychneuroimmunology [20,21]; and biological models disease, drug and alcohol abuse, and lung cancer [2]. linking the social world and physical health [22-24], to After some success in applying psychological theory and name a few. practice to the promotion of physical health, health psy- Underlying this multifarious collection of research chology formally became Division 38 of the APA in within health psychology is the position that biological 1978. Since then, research in health psychology began to (e.g., genetic predisposition), psychological or behavioral focus on diverse areas, including: illness treatment and (e.g., lifestyles, explanatory styles, health beliefs), and prevention; the role of psychological factors in health social factors (e.g., family relationships, socioeconomic and illness; and improving health care services and poli- status (SES), social support) are all implicated in the cies [3-5]. Today, Division 38 has over 6000 formal various stages of pathogenesis and health etiology. This members, one of the largest in the American association, position is termed the “Biopsychosocial Model” (BPS) and includes several rigorous research programs, involv- and has gradually emerged in consort with related scien- ing: associations among clinically diagnosable mental tific developments in medicine. During the evolution of

Copyright © 2012 SciRes. OJMP 52 A. R. HATALA medical science from the Renaissance to the late 19th complex “health risk behaviors”, these authors suggest and early 20th centuries, advances in biology, anatomy researchers must investigate one’s cultural, peer and and physiology eventually crystallized into what is now family environments, one’s propensity to risk taking and referred to as a “biomedical model”. This perspective emotional reactivity, as well as one’s genetic and bio- yielded a shared set of assumptions (i.e., reductionism, logical predispositions [33]. Underestimating any of naturalism, mind-body dualism), which relegated illness these three domains, these authors argue, will limit a and healing primarily to a physiological framework with practitioner or researcher’s ability to predict the likeli- limited attention to social, moral or political dimensions. hood of initiation, rapidity of addiction, and the difficulty It is during this time in the late 1970s that psychiatrist of cessation [33]. George L. Engel at the University of Rochester, as well The status of the BPS model, its use and general ac- as other clinicians and researchers, began to enunciate ceptance within health psychology, however, is not free the limitations of biomedicine and a need for a biopsy- from contestation. Several authors over the years have chosocial perspective1. In 1977 George Engel observed a expressed concerns regarding its limitations, specifically “medical crisis” that he thought “derives from adherence regarding: problems with dichotomizing between biology, to a model of disease no longer adequate for the scien- psychology, and society [27]; problems with its ambigu- tific tasks and social responsibilities of either medicine or ous status as an actual “scientific model” [34-36]; prob- psychiatry” (p. 129), and that medical practitioners and lems of masking an underlying biomedical approach researchers “should take into account the patient, the [37,38]; difficulties with the complexity of outlining lin- social context, the physician’s role and the health care kages or prioritizing among its subsystems [26,39-41]; system” (p. 132) [25]. Engel’s articulation of a “biopsy- and a pervasive individualistic focus [14,18,42,43]. chosocial” perspective was therefore an important at- Despite original goals, researchers in health psychol- tempt to incorporate the patient’s psychological experi- ogy and related medical fields have developed theoretical ences and the social or cultural context into a more com- integrations across biopsychosocial domains only to a prehensive framework for understanding disease, illness limited extent. Consequently, health psychology largely 2 and health . operates from what several authors suggest is a “psycho- Since its introduction, the BPS model has been widely somatic” framework [26,39,40]. In their 2004 review of embraced within medical sciences and health psychology. the BPS model, for example, Suls and Rothman inde- Presently, the American Psychiatric Association and the pendently read and coded all of the studies published in American Board for Psychiatry and Neurology, as well Health Psychology—a leading journal in the field-over a as several medical schools, psychiatry residencies, and 12-month period (November 2001-September 2002). health psychology graduate programs across North They observed that 94% of the studies assessed psycho- America and Europe officially endorse a biopsychosocial logical variables only, with minimal attention given to approach [26-27]. Furthermore, several health psycholo- larger socio-cultural factors [41]. These authors observe gists in particular consider the BPS model to be a guiding that “opportunities to explore the interconnections be- framework for contemporary research and practice [28- tween biological and social factors appear to have been 30]. In the context of chronic pain, for example, a 2004 limited” and conclude that “researchers have taken the study by Gatchel and a 2007 study by Gatchel and col- basic tenets of the biopsychosocial model seriously, but leagues both demonstrate that the connections among more could be done to pursue the linkages among sub- biological changes, psychological status, and the socio- systems” (p. 121) [41]. Thus, a central issue regarding cultural context should all be considered in trying to un- the BPS model and its use within contemporary health derstand an individual’s perception of pain [31,32]. A psychology and related medical fields involves the de- psychiatric intervention or treatment approach, Gatchel gree to which the three domains of the model are ex- further argues, “that focuses on only one of these core plored in an “integrative” framework [44]. sets of factors will be incomplete” (p. 797) [31]. In 2008 The current paper addresses this issue by outlining and Leventhal and colleagues paint a similar picture for ad- making connections across research findings in health dictions, smoking and alcohol use. To understand these psychology in order to strengthen the associations among 1In 2009 Ghaemi observes that the “biopsychosocial” concept was bio-psycho-social domains while at the same time argu- actually coined by Roy Grinker in the 1950s. George Engel, however, ing for a richer, more nuanced approach to “culture” is still largely responsible for its popularization in medical science and within the current biospychosocial meta-theoretical frame- health psychology in his 1977 article [26]. 2For the current purposes, disease is defined as “an objective biological work. Thus, it is proposed that a “holistic” perspective is event” involving the disruption of specific bodily structures or organ required to guide future research and practice in health systems caused by either anatomical, pathological, or physiological psychology and related medical fields, a perspective that changes; and Illness is defined as a “subjective experience or several developmental psychopathologists and research- self-attribution” that a disease, or psychosocial “disturbance” is present [60,61]. ers refer to as a multilevel integrative analysis [22,45-48].

This guiding perspective is inherently multidisciplinary ing food intake, physical activity, and cigarette smoking, and multiparadigmatic and assumes equality within all are causally related to the management and vulnerability levels of analysis (i.e., genes, neurological structures, of chronic psychological and physiological disorders, and psychological traits, families, peer groups, and broader are negotiated within larger socio-political and cultural contextual influences like culture and ethnicity) thereby discourses, several authors suggest a focus on health be- attempting to dismantle conceptual borders between na- haviors necessarily engenders biospychosocial perspec- ture and nurture, biology and psychology, or science and tives [6,22,31,32,]. Indeed, Leventhal and associates spirituality [47,48]. poignantly suggest that although statistical models in To meet these ends, this article first critically reviews community epidemiology and social psychology have studies in health psychology in an attempt to flesh-out or highlighted ecological, economic and sociocultural ef- strengthen the relations among the domains of the BPS fects on health and illness, many of these effects are ac- model and introduces the fields of and related findings in tually produced at the level of behavior [33]. sociosomatics, neuroplasticity, and psychosocial genom- According to Baum and Poslunsny, behaviors influ- ics. Following this, a review of the concept of “culture” ence health in three interrelated ways [6]. First, they may is presented to further strengthen the relations among induce direct biological changes due to emotional reac- bio-psycho-social domains. In the end, clinical implications or specific behavior patterns. Second, behaviors tions are discussed. may convey risk or protection from disease. Here, health- enhancing behaviors are understood to act as protection 2. Biopsychosocial Perspectives against disease or illness (e.g., diet or exercise, etc.), whereas health-impairing behaviors are understood to 2.1. Psychosomatics, Behavior & Health produce harmful effects (e.g., alcohol abuse, smoking, A considerable number of empirical findings unequivo- etc.). Third, patterns or cultural narratives of and for ill- cally support the notion that psychological and behav- ness behavior, such as interpretations of symptoms, deci- ioral factors have important implications for disease, sions to seek care, or surveillance methods, can exacer- illness and health. Chronic stress, depression, social iso- bate or impede the progression and manifestation of cer- lation, and conscientiousness are all understood by health tain diseases [6]. Along these lines, some researchers psychologists and medical colleagues alike to impact the (e.g., [52]) now identify specific cognitive heuristics vulnerability to or protection from certain diseases [7, people draw on to interpret and thus give meaning to 49,50]. Clinical depression in particular is consistently negative somatic events and their appropriate behavioral correlated with the occurrence and pathogenesis of car- responses. People diagnosed with major depression, for diovascular disease (CVD). In one recent 2009 study, for instance, consistently demonstrate lower adherence to example, Salomon and colleagues examined differences treatment regimens [53], and lower care seeking behav- in cardiovascular reactivity to and recovery from two iors [54]. Taken together, research into psychosomatics laboratory stressors between naturalistic samples of clin- [7], and health behaviors [33] provide initial insights into ically depressed (N = 25) and healthy controls (N = 25) the relations among the domains of the BPS model. with no self-reported history of CVD [7]. Their results It is important to pause and reflect here on a number of indicate that depressed individuals exhibited both lower criticisms that can be leveled against the previously re- heart rate recovery and reactivity compared to controls. viewed studies. Perhaps most relevant for our purposes Salomon et al. conclude that “although depressed par- of seeking a deeper integration between the three do- ticipants exhibited less reactivity and a higher resting mains of the BPS model is the prevalent individualistic heart rate (HR), … they continued to exhibit elevated HR focus of many previous studies in health psychology during the recovery period” (p. 163) [7]. Other researchs [18,43]. Researchers operating from “biopsychosocial” note that common features of depression such as dyspho- perspectives are often informed from Bronfenbrenner’s ria or rumination, for example, have been related to per- ecological models developed in 1979 in which a variety ceiving stressors as more severe in addition to reduced of concentric circles (family, school, work, cultural prac- self-confidence and optimism [51]. Thus, depression may tices, political systems, etc.) simply expand around and confer risk for CVD through alterations in perceptions of envelope the individual at once the center of analysis, demanding situations that impair recovery from envi- interpretation and intervention [55]. Is this a meaningful ronmental stress. way to envision potential biopsychosocial interactions in Another prominent and related line of research ex- health psychology? Is biology at the center with psy- plores behaviors as the space in which biological, so- chology and socio-cultural factors merely adding layers cio-cultural and psychological factors intersect to impact of complexity to a stable core? disease, illness and health. As human behaviors, includ- As we saw, Salomon and colleagues primarily exam-

Copyright © 2012 SciRes. OJMP 54 A. R. HATALA ined psychosomatic relations with little attention to the ciosomatic research is therefore primarily the study of socio-cultural context that often impacts or informs in- social processes and explores how health, illness and terpretations of perceived environmental stressors [7]. disease are mediated at broader, often collective, socio- Similarly, studies that investigate health behavior have cultural or political levels. Thus, the moral, cultural, po- also been limited in the extent to which meaningful or litical, economic and medical become intertwined in a complex interactions between the individual and the so- complex web of significance, possibly a reflection of cial or cultural worlds are explicated [33]. Indeed, these George Engel’s original vision of a “new” medical model “decontextualized” positions are common within “clini- some twenty years prior [25]. It is suggested that re- cal” health psychology, as several authors observe search carried out from this so-called sociosomatic per- [18,56], and thus in their succinct review of the BPS spective can help strengthen the bio-psycho-social im- model and its use within health psychology and related plications of health, illness and disease3. medical fields, Suls and Rothman urge researchers and In an interesting sociosomatic case study of a Puerto funding agencies to view the much needed complexity in Rican woman suffering from depression and domestic research and practice as a virtue rather than vice [41]. traumas, Jenkins and Cofresi present an interrelated set With these considerations in mind, and although pre- of themes extracted from the patient’s narrative (i.e., trust vious research demonstrates significant psychosomatic (confianza), malevolence (maldad), nerves (nervios), to and behavioral associations among health, illness, and suffer (sufrir), to unburden oneself emotionally (desa- disease, future studies and the continued development of hogarse)) that reveal connections between somatic and the BPS model may depend upon both a movement away social processes [57]. These authors suggest that narra- from an overly individualistic focus and an embrace of tive themes constitute tools for the emplotment of the sufficient levels of analytic complexity (i.e., multilevel woman’s story that became a “symbolic bridge” [60,61] integrative analysis). It is suggested that a review of so- between disrupted social relationships and somatic pres- ciosomatics, neuroplasticity and psychosocial genomics entation. In other words, Jenkins and Cofresi suggest that will help to balance out what may be an individualistic depressive symptoms, such as ruminations about suffer- bias in health psychology, provide an adequate and so- ing, irritable mood, or suicidal ideation, become under- phisticated understanding of the socio-cultural contours stood as “social conditions of distress” or “global expres- underlying health and illness, and foster a greater inte- sions of suffering” rather than an isolated or idiosyncratic gration among bio-psycho-social domains. set of clinical expressions (p. 446) [57]. In a similar manner, Kirmayer and Young identify the means by 2.2. Sociosomatics which somatic symptoms can metaphorically reflect expressions of socio-cultural distress or moral wrongs [58]. In a special issue of Psychosomatic Medicine, Arthur These authors review epidemiological and anthropologi- Kleinman and colleagues draw connections between cal evidence from a variety of cultural perspectives and psychosomatic research and what they term “socioso- suggest that, depending on circumstances, somatization matics” in an attempt to illustrate the nature of a dialectic can be conceptualized from within multiple interpretive process between somatic, psychic and social processes, frameworks, including: 1) an index of disease or disorder; or the intercommunications among body, mind and soci- 2) a symbolic expression of intrapsychic conflict; 3) an ety [57-59]. In 1986 Arthur Kleinman from Harvard idiomatic expression of distress; 4) an act of positioning Medical School introduced the term “sociosomatic” in an within a local social world; or 5) a form of social com- attempt to refocus attention in the health sciences on the mentary or protest. Therefore, Kirmayer and Young often neglected social etiology of illness and disease. In highlight the fact that a “psychologized” approach to challenging the familiar “psychologized” understanding somatization reflects only one “Western” cultural orien- of somatization as an individual and intrapsychic media- tation and that theories of somatization must be expanded tion between psychological and physiological processes, to recognize more often the social meanings of bodily Kleinman argues that a more fruitful orientation becomes distress [58]. “mind-body-in-context,” thereby situating distress within Overall, sociosomatic research that outlines how bod- the social and cultural world [60-62]. In this way, and from these perspectives, “sociosomatics” signifies: 1) the 3Culture, from these perspectives, tends to signify a “tacit” way of social context being integrated into mind-body interac- being-in-the-world involving a shared set of symbols and metaphors used both in the context of an individual’s “local social world” as well tions; 2) the impact of social context upon bodily or ill- as broader socio-political discourses [61]. The term “socio-cultural” is ness experiences (i.e. the social construction or social used heuristically throughout this paper in an attempt to reflect both course of the illness experience); and 3) the somatic me- the local and global aspects of cultural systems. Although difficult to draw distinctions, “socio-political” is also used heuristically to reflect taphor of social disharmony or the symptomatic expres- “societal” issues such as poverty, or social economic status. In later sion of collective experiences such as distress [62]. So- sections, issues of “culture” are discussed in more detail.

Copyright © 2012 SciRes. OJMP A. R. HATALA 55 ily dynamics are often shaped through complex interac- other researchers suggest that processes of reconstructing tions among subjective experiences, cultural meanings, memories of past trauma during psychotherapy or narra- and situated contexts, not only help to integrate-at con- tive interventions are supported by actual neurological ceptual and practical levels-the bio-psycho-social do- reorganization and neurogenesis [71]. Because neuro- mains, but also help to overcome individualistic “psy- plasticity is thought to “play out” via experience-depen- chosomatic” biases so often associated with health psy- dent gene interactions, psychosocial genomics thus be- chology in particular or “mainstream” psychology more comes an excellent complement to this neuroplasticity generally [18,60]. As interesting and relevant as socio- research. somatic studies are, however, limitations remain in the Psychosocial genomics observes and describes the extent to which they fail to adequately explain, or inter- modulating effects of experience on gene expression— pret, how socio-cultural variables “get under the skin” in essentially support for and a reformulation of the well- order to influence the physiological pathways or genetic known gene-environment interactions [45,72]. Protein processes leading to disease and mortality [23,63]. Thus, synthesis within the DNA code of the human genome is although sociosomatic research is relevant to balance subject to modifications beyond changes within the basic what Suls and Rothman observed in 2004 as a focus on genetic sequence of amino acids themselves and there- “psychosomatics” in clinical health psychology [41], it is fore do not occur in a one-to-one fashion [72,73]. Instead, suggested that psychosocial geonomics and neuroplastic- protein synthesis is highly vulnerable to social-environ- ity can take us one step further in our desired integration mental signals (i.e., experience-dependent gene expres- across bio-psycho-social domains insofar as socio-cul- sion), which not only turn specific genes “on” or “off”, tural experiences are implicated not only within overt leading to alterations in protein synthesis [45,72,74], but somatic expressions, but within complex physiological also modulate, steer or modify the manner in which basic pathways and genetic processes as well. organic molecules are organized into anatomy and physiology [75]. Rossi, for example, suggests that our 2.3. Neuroplasticity & Psychosocial Genomics genes provide a framework for development, the “warp” Over the last decade, rapid advances in molecular biol- threads of a loom to use a metaphor; whereas, socio- ogy and genetics gave way to the complete mapping of cultural experiences and environmental influences can the human genome in 2001 [64]. Alongside these devel- alter gene expression and thus form the “woof” threads. opments were technological and spectral imaging ad- Psychosocial genomics is the term used in 2002 by Rossi vances, such as functional magnetic resonance imaging to represent this complex “weaving” interaction, which (fMRI), allowing us to examine complex neurological can potentially help integrate biopsychosocial domains as processes. Together these scientific movements spawned presented and used within health psychology and related two relatively recent fields of empirical investigations, medical fields [76]. neuroplasticity and psychosocial genomics, offering im- Social support has long been thought of as an illness portant evidence regarding the interrelated and interde- protective or health-promoting factor among health psy- pendent nature of biological, psychological and socio- chologists and medical practitioners, and can be explored cultural processes. here to explicate these complex biopsychosocial interac- Research on human neuroplasticity demonstrates that tions. Across a large number of studies, individuals with brain neurons are considerably more dynamic than was more satisfying social relationships or confidants (i.e., once thought and can develop novel synaptic connections someone they can talk to about problems), recover more in response to experience and learning across the entire quickly from already-diagnosed illness and reduce their life span into and including old age [47]. Prior to 1998, risk of mortality from specific diseases when compared it was commonly held that the neurophysiology of the with those with less social support [6,20,23,24,33,77,78]. human adult brain was fixed and immutable. Acceptance Previous research also suggests that social support may of the “hardwired brain” started to collapse, however, buffer or protect against the effects of negative environ- after a thought provoking paper was published in 1998 mental stressors on immune processes [79], and may also by Eriksson and colleagues describing the growth of new foster restorative physiological process, such as more neural tissue or “neurogenesis” of the adult hippocampus efficient sleep [80]. Questions remain however as to how [65]. Since then, neuroplasticity has been observed and social support can “get under the skin” so to speak. From documented in a variety of conditions and experiences a psychsocial geonomic perspective, experienced social [66-69]. McGaugh, for example observes how hippo- support may be seen to increase physiologic control of campal changes can appear within adult brains only potential inflammation by the hypothalamic-pituitary- hours after challenging learning experiences, hypothe- adrenal (HPA) axis creating altered gene expression pro- sized to develop analogously to the ways that strenuous files in immune cells [75,76,81]. In other words, the bio- physical labour can develop muscle tissue [70]. Similarly, logical underpinnings of a specific disease (e.g., CVD)

Copyright © 2012 SciRes. OJMP 56 A. R. HATALA and various socio-cultural experiences (i.e., social sup- nature of their research? The following section explores port), from this perspective, are etiologically equivalent. these questions to further strengthen the sought after “ho- The practical implications of this psychosocial geo- listic” perspective among bio-psycho-social domains. nomic “equivalency” suggests that health interventions or “healing” at one level of organization (i.e., biology, 3. “Culture” in the Biopsychosocial Model psychology, family, community, etc.) can create a ripple The concept of culture has evolved over the years, effect that impacts all other levels—that is, talk therapy, changing from context to context and situation to situa- for example, may have as much of a psychological im- tion, carrying with it a certain “vagueness” and conten- pact on an individual as neurological, genetic or so- tious nature [83,84]. Conceptions of culture in positivist cio-cultural [82]. Therefore, recent calls for heightened psychological discourse often focus on broad homoge- “social action” or “social justice” initiatives in health nous factors that are likened to a “bounded group” which psychology [10-13] should be understood to impact can then be easily compared to another group on a par- broader socio-political domains known to effect health ticular characteristic of interest (i.e., American, Chinese, status (i.e., poverty, social inequalities, social economic and Russian etc.) [85]. Along these lines, positivist health status, etc.), as much as psychological, genetic and bio- researchers—those seeking to explain aspects of and logical domains. This argument is also clearly outlined make predictions pertaining to human reality through the by Lawrence Kirmayer at the University of McGill sug- identification of its universal features—tend to draw on gesting that “in practice, every therapeutic action or conceptions of culture from early 19th century theorists communication—whether drug, word, gesture, ritual or such as E. B. Tylor who referred to culture as a complex relationship–has effects simultaneously on all these lev- whole that includes knowledge, belief, morals, law, and els” (p. 42), and that “there is little evidence to support other habits and capabilities acquired by people as mem- the claims of particular schools of psychotherapy that a single mechanism like catharsis, insight, reinforcement bers of a particular social group [86]. In addition, con- or cognitive restructuring alone accounts for the efficacy temporary cultural conceptions are also influenced by of its practice” (p. 42) [15]. Moreover, previous concerns researchers like Kroeber and Kluckhohn who, in 1952, voiced by researchers over how to prioritize across examined existing definitions of culture in their time and bio-psycho-social domains [26,40] are, from this multi- offered a synthesized understanding wherein, “culture level integrative perspective, unwarranted insofar as they consists of patterns, explicit and implicit, of and for be- presuppose dichotomies that, in effect, may not be pre- havior acquired and transmitted by symbols, constituting sent. In other words, socio-cultural experience must be the distinctive achievements of human groups…” (p. 181) taken as analytically “equivalent” to biology and psy- [87]. More recently, George Barnett and Mehihua Lee chology, and this is the deeper integration sought be- add to the growing cultural discourse by synthesizing tween domains. Thus progress in health psychology and Geertz, Durkheim, and Goodenough to define culture as: the continual maturing of the BPS model may come from “a property of a group. It is a group’s shared collective looking at how any and all of these levels are involved in meaning system through which the group’s collective even the simplest of interventions [15,76,82]. values, attitudes, beliefs, customs and thoughts are Taken together, this section briefly reviewed three ar- understood. It is an emergent property of the member’s eas of research that potentially contribute to a deeper social interaction and a determinant of how group integration among BPS domains: psychosomatics and members communicate” (p. 277) [88]. behavior; sociosomatics; and neüroplasticity and psy- Taken together, these conceptions of culture—focus- chosocial genomics. Findings from these fields validate ing solely on the properties of distinct groups—encour- the importance of BPS perspectives in health psychology age researchers to exaggerate distinctions while dis- insofar as they outline the relations between mind, body counting similarities. and society as well as elucidate the mechanisms by Several cultural theorists, such as Keesing, argue that which socio-cultural forces can “get under the skin” previous positivist conceptions of culture—like those [23,82]. Although the review of these areas may be rele- mentioned above that focus on global factors of group vant to our goal of creating a deeper integration across membership only—tend to espouse a kind of “radical bio-psycho-social domains, the question of “culture” in alterity,” exaggerating exotic elements of different cul- the BPS model still remains. What is the role of “culture” tural systems while overlooking elements in common in relation to biological, psychological and social aspects [89]. In 1990 Keesing argued for a move away from de- of health research? Is it subsumed within the “social” finitive definitions of culture so to avoid issues of reifi- domain or something entirely separate? What is more, cation, essentialism, or to mistakenly presuppose the idea how do health researchers and practitioners conceptual- that cultures are “hermetically sealed” or bounded to a ize “culture” and how do these perspectives impact the particular time or location. In this regard, medical re-

Copyright © 2012 SciRes. OJMP A. R. HATALA 57 searchers such as Arthur Kleinman advise that culture be tain individuals are thought of as being members of par- conceptualized as “what is at stake” for particular indi- ticular “cultural” groups, how this is determined, and viduals in particular situations, with a focus on “collec- whether or not these distinctions are meaningful. Such tive (both local and societal) and individual (both public critical questions not only aid global health and medical and intimate) levels of analysis” (p. 98) [61]. From this research in an ever expanding multi-cultural or global- perspective, culture moves from the exotic rainforests of ized context, but also, and perhaps more importantly, the South American Amazon to the everyday lives of augment the sought after associations across bio-psycho- North American Wal-Mart shoppers, suggesting that social domains. whatever is at stake for individuals within their particular In both the previously cited studies, justification was local social worlds involves, in some way or another, not given for how or why Christian, Muslim, or Hindus, cultural systems [83]. In other words, for “culture” to be for example, were considered to be meaningfully distinct meaningfully conceptualized within empirical research it groups. In many so-called “cross-cultural” studies in- arguably must be brought to the level of individual local formed from positivist assumptions, self-ascribed reli- social and moral experience thereby maximizing the in- gious affiliation represents a sufficient marker for cul- dividuated meanings and interpretations of cultural sym- tural difference. Substantial evidence against this as- bols while minimizing reified group distinctions. sumed cultural or religious uniformity has been formu- In contemporary health research carried out from “bi- lated, however. For example, Douglas Hollan, during his opsychosocial” perspectives, a central limitation involves fieldwork amongst Toraja men in Indonesia, concluded cultural assumptions of uniformity or homogeneity with- that no two people internalize the symbolic systems in sample groups. It is not uncommon to see religious available within a particular cultural landscape in the denomination (Evangelical Protestant, Roman Catholic, same way, and that “cultural processes must be highly Hindu, or Muslim) or “cultural orientation” (North dynamic and ever changing because the minds and American, African, or Asian) taken as a proxy for or re- self-states of the people who embody and enact them presentation of an isolated group that can be then mean- are” (p. 545) [92]. These data suggest that a group of ingfully compared to a different group. In their 2002 individuals who self-ascribe to the same religious or cul- examination of the relation between spiritual striving and tural system (Roman Catholic, Seventh Day Adventists, psychological health, for example, Piedmont and Leach Hindu, Buddhist, Muslim, or Bahá’í) will have important administered the Spiritual Transcendence Scale (STS) in differences as to the ways in which the symbolic forms a “cross-cultural setting” involving over 350 individuals found within their particular religious or cultural universe from Christian, Muslim and Hindu religious backgrounds are taken in, internalized and lived. The knowledge of or who were English speaking and living within the Hy- devotion to certain symbolic dimensions, such as values, derabad region of India [90]. Their goal was to validate beliefs or levels of practice in a religious or cultural sys- spirituality as a universal aspect of human experience tem, is likely to vary significantly between individuals. related to adaptive psychological functioning by com- Therefore, the knowledge of a particular cultural trait (as paring findings from the three religious groups. These it may be examined on a given quantitative measure for authors concluded that the STS was an appropriate health research) must be seen as different from that trait measure that could be used to generate knowledge of having a personal, internalized meaning. In other words, spiritual transcendence in cross-cultural and multi-reli- individuals may “share” the knowledge of a particular gious settings and that psychological health and spiritual cultural trait, yet it is likely that the trait is “lived” in dif- striving were positively correlated. Similarly, a more ferent ways by different individuals [83]. This perspec- recent study conducted in 2006 by the World Health Or- tive has serious implications forcing medical researchers ganization Quality of Life research group, attempted to to question the assumptions of homogeneity within cur- examine the relation among spirituality, religion and rent investigations across bio-psycho-social domains, not personal beliefs (SRPB) and measures of Quality of Life only within “cross-cultural” contexts, but also within (QoL) in cross-cultural contexts [91]. This study in- studies involving between-group comparisons. volved over 5000 participants from 18 different countries A second issue regarding assumptions of homogeniety that were grouped and compared by both religious af- within current cross-cultural research involves De filiation and ethnic orientation. The overall conclusion of Munck’s illustration of cultural overlap and issues of the study showed that measures of QoL demonstrated national identity, race and ethnicity [93]. De Munck ar- significant positive correlations with spiritual, religious gued that individuals from different “cultural areas”, and personal beliefs and that the SRPB instrument was such as India and Canada, may simultaneously share useful to investigate the differences in QoL among dif- similar and different local social experiences. For exam- ferent cultural groups [91]. It is imperative to question ple, if we imagine three individuals, a female organic “cross-cultural” studies of this kind regarding why cer- farmer and vegetarian in Saskatchewan, Canada, a suc-

Copyright © 2012 SciRes. OJMP 58 A. R. HATALA cessful multimillionaire male lawyer in down town To- all aspects of the BPS model. Neglecting to pay adequate ronto, and a female multimillionaire from Calcutta, we attention to the important, if not central, role of culture in can see experiential similarities and differences across all health psychology and related medical fields can lead to three. Positivist or modernist theories of culture, focusing several concerns as Kazarian and Evans observe: the primarily on group affiliation, would argue that the fe- neglect of cultural and linguistic demographics in health male organic farmer and Ontario lawyer are “culturally” care delivery; the lack of consideration of cultural diver- more similar than either is to the millionaire from Cal- sity in health service planning, implementation, and cutta. But clearly there are experiences that the Canadian evaluation; the creation of discriminatory health service organic farmer and the millionaire from Calcutta share in practices and disparities in health care access, utilization common as women and vegetarians, while at the same and outcome; and the marginalization of a diverse array time the lawyer from Toronto and millionaire from Cal- of indigenous health structures, belief systems, and prac- cutta also share common experiences as urban dwelling tices [14]. Therefore the role of culture must be seriously multimillionaires [93]. This suggests that when culture is considered when attempting to integrate the three aspects conceptualized only in terms of the broader collective of the BPS model into a more holistic perspective. societal levels, discrete cultural areas (Canada or India), ethnic identities (Indian, Chinese, or Irish) or particular 4. Conclusions: A “Holistic” Approach races (black, or white), important experiential distinc- At its inception, there was minimal empirical evidence tions are masked regarding what is at stake for particular supporting the importance of a biopsychosocial approach individuals in particular contexts. Moreover, when na- to health promotion [25]. After several decades of re- tional boundary or ethnic identity is taken as a proxy for search in health psychology and related medical fields, cultural orientation, this serves to physically and tempo- however, the support for a biopsychosocial perspective is rally bound dynamic cultural systems. Individuals who growing. Limitations in previous conceptions of the BPS self-ascribe to similar cultural systems or philosophies model are arguably being overcome as research into so- yet differ greatly with respect to local experiences cannot be meaningfully placed together in a single group and ciosomatics, neuroplacticity, and psychosocial genomics compared against another group. Therefore, if group af- are beginning to explicate the complex ways in which filiation is to be determined for research purposes, this social factors impact health outcomes and somatic may best occur by an examination of the individual’s symptoms as well as the ways in which socio-cultural local social and moral world or context dependent ex- forces “get under the skin.” In following a multilevel periences, rather than simply looking at the broader cul- integrative analysis [45-48]—which takes into account tural orientation or self-ascribed cultural or religious af- multiple levels of orientation—it is suggested that health filiation. In this way, what Schwandt calls interpretivist, research and successful health promotion necessarily hermeneutics, or social constructionist epistemological involves the dynamic interaction of biological, psycho- positions [94], positions that seek to pull apart and un- logical, and social domains, while at the same time understand the local, moral and experiential realities of in- derstanding the role of culture that informs and saturates dividuals, and the related methodological approaches all three. such as qualitative phenomenology, narrative inquiry, In terms of clinical implications, this review suggests ethnography, or case study analysis, may become more that future health intervention strategies and research appropriate as researchers in health psychology and re- programs should focus on the “holistic” interaction be- lated medical fields continue to increase the sophistica- tween these domains rather than addressing them as sep- tion with which group membership is determined in arate aspects of the individual or environment. The con- cross-cultural settings [95-97]. tinual maturing of the BPS model may therefore depend Overall, this brief review of the role of “culture” in upon the extent to which any and all of these levels (ge- health psychology and the BPS model would suggest a netics, biology, psychology, sociality, ecology, culture, more nuanced position as opposed to simply equating and spirituality) are involved and overlap within even the cultural orientation with the social domain. Culture, as simplest of interventions [14]. As Sulmasy clearly out- viewed from the position of what is at stake in one’s lo- lined: cal social and moral world, impacts not only the social “A human person is a being in relationship—biologi- embeddedness of individuals (i.e., family relationships, cally, psychologically, socially, and transcendentally. socioeconomic status (SES), social support, political Illness disrupts all of the dimensions of a relationship structures, laws, etc.), but also the psychological or be- that constitute the patient as a human person, and havioral (i.e., lifestyles, explanatory styles, health beliefs) therefore only a “holistic” or biopsychosocial-spiritual and the biological (i.e., genetic predispositions) as well model can provide a foundation for treating patients [61]. Thus, culture informs, is a part of, and influences holistically” (p. 32) [98].

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