Not Getting Better? Insist Upon The Biopsychosocial Model (Part 1)

The Biopsychosocial Model

Almost half of the new patients that come to our practice have been recently treated by two or more psychiatrists and/or psychotherapists, and have not recovered from their illness. Some have not gotten better and in fact are getting worse; others have not achieved full remission. They describe that they don’t feel well, or “feel sick.” Usually they have not been evaluated and treated as a Whole Person, under what is known as The Biopsychosocial Model.

When the psychiatrist who practices under the Biopsychosocial Model engages in psychotherapy, they can integrate a knowledge base comprising neurobiology, genetics, general medicine, the unconscious, behavioral science, family systems, workplace/environmental stressors, and nutrition, to design and implement personalized and precise treatment plans.

Sandra’s Story

An example of the biopsychosocial model in action can be illustrated by the treatment of Sandra, a 34-year-old physician with depression and anxiety stemming from multiple stressors and losses. As you will discover, evaluating and treating her as a whole person took patient, persistent effort on both of our parts, and several years of working together to achieve full remission.

Some of the themes of Sandra’s life are well captured in the lyrics of the Coldplay song, “Paradise”. One interpretation of this emotionally moving song is that it depicts a young girl who at first is filled with optimism about her prospects in the world. Then the sadness and heaviness of life begins to fill her heart. To cope with her tears, at night while sleeping, she dreams of a paradise. As the storminess of life is about to engulf her, she comes to feel that “the sun is set to rise” and begins to feel hopeful once again.

Sandra also felt happy in childhood, was an extremely good student with a great deal of ambition, and rightfully believed she could go out into the world and make quite a name for herself. However, as certain events began to unfold and overwhelm her emotions, she dreamed of escaping the circumstances that were bringing her great sadness and aloneness – and dreamed of a future paradise free of any emotional pain.

Sandra’s life began to change at age fifteen, when her mother became ill with an unexplained disease which initially presented with persisting muscle weakness, fatigue, and dropping objects that she was holding in her hands.

After about a year she was diagnosed with a rare, progressive, and ultimately fatal neurodegenerative disease for which there was minimal treatment and no cure. Her illness deeply saddened Sandra as she watched her mother’s steady decline with helplessness and horror, but she wouldn’t allow herself to grieve, and coped with her feelings by throwing herself into her studies, eventually attending a prestigious college and medical school, and graduating with honors as a member of Alpha Omega Alpha Honor Medical Society, at about the time that her mother passed away.

As a child watching her mother’s relentless decline, Sandra coped with the horror she felt by imagining herself in an ideal life – wealthy, powerful, and filled with the love of a man – which was a central organizing fantasy[1] that kept her going. At the time of her mother’s death she kept her feelings to herself, and focused instead on her relationship with her boyfriend Sam, and on finding a job. Hired by a university hospital medical center in downtown Washington, DC, she immediately threw herself into her research, teaching and clinical responsibilities. Several times a year she and Sam would vacation at exciting locales around the world as they were avid sailors and mountain climbers, always seeking out the next adventure. Eventually they became engaged to be married and that’s when her symptoms of anxiety and depression began to surface.

Sam’s mother was a very difficult and meddlesome woman who began to almost immediately interfere with their relationship, letting Sam know that Sandra (who came from a different racial background than Sam- her family was of Asian Indian descent and his was WASP) was not suitable for him. At family dinners and on one particular vacation that they all took together Sam’s mother would shun Sandra or disparage her family. For example, when they were all seemingly enjoying a relaxing evening and in the middle of a lively discussion, she tactlessly pointed out that two acquaintances’ children had “married people of color” and had confided in her that they were distressed over this. She then began talking about “the unbearable burden” that one of her friends was facing in caring for a husband with a neurodegenerative disease – and how her friend had understandably found a lover on the side to cope with the situation. These insensitive remarks made Sandra feel devastated, and she sought out therapy with me.

As she recounted this story, I recalled what it felt like to watch one of my own family members, a wonderful, bright, energetic woman, steadily decline following a massive stroke, and empathized with her, “Sandra, you may have felt utterly helpless watching your mother’s inexorable decline toward death. It is a horrifying experience, filling one with grief. Up to this point you have been unable to fully grieve her illness and death. The callous insensitivity of your future mother-in-law, and her interference with your relationship with Sam, is also an important issue. Perhaps, if it is alright with you, we will address Sam’s mother later on after we have spent time talking about your mother’s life and your relationship with her.” Sandra agreed and she began to share her memories and feelings about her mother’s life, prolonged illness, and death.

Other lyrics from the song “Paradise” poignantly capture the transformation of Sandra and her world during the period when her mother first took ill and began her relentless decline. When Sandra first presented she indeed felt “broken,” and that her life was so heavy she could no longer bear to live it. She felt that if she began to cry – began to grieve her mother’s death – she would never stop crying for the remainder of her life (every tear a waterfall). Since childhood Sandra had dreamed of a future free of the overwhelming pain that she felt inside, and we began to work together to facilitate her grieving, traveling down a long road to healing her broken heart. To help her use the talk therapy more effectively, it was important to simultaneously treat the biologic aspects of her depression.

In Part Two of this series, you will learn about how we began to “untangle” Sandra’s brain, as we continued to work together in psychotherapy.

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