■ Research PaperGeneral Systems Theory Its Past andPote.docx

■ Research Paper
General Systems Theory: Its Past and
Potential†
Peter Caws1,2*
1Department of Philosophy, The George Washington
University, Washington, DC, USA
2American Association for the Advancement of Science,
Washington, DC, USA
This paper has three parts. First, I discuss what I take as the
original stimulus and the pur-
pose of general systems theory (GST) to be, why I think it is
important, and how I came to
be involved in it. I reflect on von Bertalanffy’s general system
(sic) theory and the early
debates on the topic, stressing the essential concept of
isomorphism, with its rewards in
following up parallel developments in different domains, and its
risks and temptations
in the projection of grand and all-inclusive systems. Second, I
discuss the direction my
own work took after my term as President of the Society for
General Systems Research
(1966–1967), and how it diverged from the early program, in
particular in its emphasis
on the difference between system and structure and on the
essential role of individual
subjectivity in the latter. I stress the importance of the concept
of ‘relation’ as underlying
that of ‘system’, and in particular the difference between

relations as embodied in physical
systems and relations as components of intentional structures
that may or may not corre-
spond to physical systems. In the third and final part, I discuss
the place of GST in the
philosophy of science, especially in connection with the unity
of science movement, and
its potential for the organization of this domain. I ask what light
the concept of system
can throw on our knowledge of the universe and its worlds (a
distinction explained in
the paper), and what the risks are of assuming tight
isomorphisms between mathematical
structures and physical systems, for example, in cosmology and
quantum mechanics.
Copyright © 2015 John Wiley & Sons, Ltd.
Keywords general system theory (GST); philosophy of science;
unity of science; isomorphism;
history of the systems movement
PART 1
It is an honor to have been invited to appear
before you today; the more so because this
lecture is named for Ludwig von Bertalanffy. It
is also an unexpected honor – I did not know until
recently that this meeting was even happening,
* Correspondence to: Peter Caws, Webb 101, Mount Vernon
Campus,
The George Washington University, Washington, DC 20052,
USA.
E-mail: [email protected]
† The Ludwig von Bertalanffy Memorial Lecture delivered at
the annual

conference of the International Society for the Systems Sciences
(ISSS),
Washington, DC, USA, on July 2014 was presented as twinned
presenta-
tions by Peter Caws andDavid Rousseau, under the joint title
‘General Sys-
temsTheory: Past, Present andPotential’. This paper represents
PeterCaws’
contribution reflecting on the past and potential of general
system theory.
Copyright © 2015 John Wiley & Sons, Ltd.
Systems Research and Behavioral Science
Syst. Res. 32, 514–521 (2015)
Published online in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/sres.2353
and although my name has regularly appeared
on the list of the Board of Distinguished Advisors
of this Society I have, as far as I can recall, never
given it any advice, distinguished or otherwise. It
is a coincidence that the meeting should be
taking place in Washington, not only at my own
university but also in my own neighborhood,
within 10-min walk from my apartment – a case
of themeeting coming tome rather thanme having
to go to the meeting. It is also a coincidence that
Tom Mandel (to whom I owe my thanks – I am
sorry he cannot be with us) should have had the
idea of bringing back, on this particular occasion,
some of the early participants in the International
Society for the Systems Sciences (ISSS) or its
precursor. If it had not been for all these things, I

probably would not have been here at all. But I
am very glad I am.
Some of what I have to say will inevitably be
autobiographical. My claim to attention is pre-
sumably that I was once President of the Society
for General Systems Research, the precursor of
your own ISSS. Bringing back a former President
after almost 50years has its risks. For one thing,
unless he has been following things closely, which
I have not, he was bound to be out of touch. For
another, anyone who has had the responsibility
of addressing an annual meeting as its President,
and who has taken that responsibility seriously,
probably is, or at any rate was, pretty opinionated.
I thought I had a necessary task back in 1966,
and I tried to carry it out; but it was not popular.
At that time, I took my job to be deflationary.
People were getting carried away by the idea of
an overarching, all-embracing system, of which
all the sciences were to be partial instantiations.
I remember in particular a paper, which I had
especially in mind in writing my address, that
argued from a local distribution of small-mouth
bass to a layered hierarchy of systems from the
microscopic to the cosmic. I thought this was
extravagant, if not megalomaniacal, and would
give systems theory a bad name, so I was at pains
to point out its limitations. As I put it in the intro-
duction to the reprinting of the address, in my
book Yorick’s World,
‘among some of my colleagues in the Society I
had detected a rampant tendency to suppose,

somewhat after the manner of Hegel, that
ontology could be read off from logic – that if
one could build a layered edifice of theoretical
systems the world must contain somewhere
their real counterparts. The argument of the
address served as a gentle rebuke to these
pansystematists’(Caws,1993, 16).
Some of my listeners probably thought I was a
killjoy – although I admit that I took some satis-
faction in the fact that, after I had made my point
in the presidential address, Anatol Rapoport
thanked me for making it and said he wished
he had done it himself.
All this was, of course, partly von
Bertalanffy’s fault, because he was something
of an evangelist for what he originally called
general system theory, in the singular, that is,
the theory of a system that would embrace the
diversity of the sciences and subsume the partic-
ular systems that he was confident would be
found repeating themselves at various levels of
complexity. To do him justice, he himself did
not yield to the lofty pretensions I was gunning
for. In his ‘Response’ to the papers offered to
him on his 70th birthday, compiled by Ervin
Laszlo as The Relevance of General Systems Theory,
he says: ‘I did not find ultimate truth or “noth-
ing-but” solutions, and never aspired toward
…. a secular “extra ecclesiam nulla salus.”
Rather, whatever I may have been able to con-
tribute, leaves plenty for others to do better’
(Laszlo, 1972, p.483),
Von Bertalanffy started at a middle level, that

of biological systems, where he introduced an
essential and most fruitful distinction between
closed and open systems, the latter providing
as the former did not for metabolic exchanges
across boundaries. Boundaries, as the theme of
this conference suggests, are crucial. However,
it is worth pausing here. Open systems can be
open in all sorts of ways – and they can be
closed by the selective admission of adjacent
elements. So the extent of the system becomes
a matter of choice – what are its elements, in
what relations, across what boundaries? This
is consistent with the definition of ‘system’ it-
self, deriving as it does all the way from its
Greek origin as nothing more specific than ‘a
Syst. Res. RESEARCH PAPER
Copyright © 2015 John Wiley & Sons, Ltd. Syst. Res. 32, 514–
521 (2015)
DOI: 10.1002/sres.2353
General Systems Theory: Its Past and Potential 515
whole compounded of several parts or mem-
bers’. But that is entirely indeterminate – what
is the whole in question?
There seems to be no obvious answer to this a
priori, as is evident from the astonishing variety
of submissions to the present conference – no
prescribed field of study, no limitations on scope.
The scope is sometimes virtually all-embracing,
as in the case of large-scale systems engineer-

ing, whose practitioners have what may seem
the grandiose task of anticipating all possible
boundary crossings at all degrees of scale or
detail and in all interacting domains, whether
natural or social, financial or logistical, physical
or biological, ecological or meteorological, etc.,
not missing any contingencies but not
overestimating any either, with huge conse-
quences for budgets and human welfare hanging
on every decision.
But I am getting ahead of myself here. I pro-
mised some reflection on what the field was like
when I got into it. I arrived in the United States,
with a degree in Physics under my belt but
not otherwise committed, at an exciting time,
catching the wave of what Gregory Bateson
characterized as
‘the growing together of a number of ideas
which had developed in different places dur-
ing the second world war. We may call the
aggregate of these’, he continued, ‘cybernet-
ics, or communication theory, or information
theory, or systems theory. …. All these sepa-
rate developments in different intellectual
centers dealt with communicational prob-
lems, especially with the problem of what
sort of thing is an organized system’
(Bateson, 1972, p.483).
This is worth dwelling on too, given how
cybernetics, and information, and communica-
tion, and our own systems, have been rivals for
dominance ever since. As David Rousseau
remarked to me yesterday, everyone wants to

be the mother ship.
I was able to switch fields to philosophy, thanks
to the generosity of Yale and my mentor there,
Henry Margenau, who used to work closely with
C. West Churchman, at that time, one of the edi-
tors of the journal Philosophy of Science, in which
I published some of my early papers. In my dis-
sertation work in 1956, I realized the importance
of the concept of isomorphism as it applied to
conceptual schemes and their mirroring (pace
Rorty) of physical structures. I did not then know
von Bertalanffy’s work, or that he had spoken
about ‘the structural isomorphy of laws in the dif-
ferent fields of science and reality’ (von
Bertalanffy, 1951), although I may have been
indirectly influenced by it, because one of my
professors was Carl G. (‘Peter’) Hempel, who
had commented on the paper in which von
Bertalanffy used the expression and may possibly
have referred to it in class.
By an accident of academic fate, my first teach-
ing job was not in philosophy but in ‘general
science’, which meant that I had to read up on
chemistry and genetics and geology, to add to
the meteorology to which I had been introduced
in school by an eager young physics teacher fresh
out of the Air Force. This constituted a pretty
good basis for doing comparative work. I special-
ized in the philosophy of science – and I have
always believed that scholars who do that must
have a first-hand acquaintance with as broad a
range of the natural and social sciences as
possible.

I gravitated naturally enough to the American
Association for the Advancement of Sciences
(AAAS) and gave my first paper to its annual
meeting during that first year of teaching. All
sorts of interesting developments were coming
to light, particularly in studies on the brain and
nervous system, and I remember being intro-
duced to the work of McCulloch and Pitts, and
reading Ross Ashby’s (1960) Design for a Brain
and of course his Introduction to Cybernetics
(1956). I do not remember how I first came across
it, but one of the formative influences at the time
was the work of an eccentric society called the
ArtorgaResearchGroup (forARTificialORGAnism),
whose president was Oliver D. Wells and whose
committee consisted of Gordon Pask, Heinz von
Foerster, Ross Ashby and Stafford Beer. Add in
Kenneth Boulding, Anatol Rapoport, Gregory
Bateson and Margaret Mead, and you get some
idea of the firepower of these early pioneers. I
did not know all of them personally, but some-
how between Artorga, the young Society for
RESEARCH PAPER Syst. Res.
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516 Peter Caws
General Systems Research, the AAAS (of which I
became Vice-President for Section L in 1967) and

my first book on the philosophy of science (Caws,
1965), I found myself delivering the address to
which I have referred in 1966.
I want to pay special tribute to Oliver Wells, a
neglected figure in this history. He self-published
a series of periodical pamphlets for Artorga and
one small book, HOW COULD YOU Be So Na-
ïve? (Wells, 1970) from his home in southern En-
gland, and was responsible for bringing a lot of
original work to the attention of his mailing list.
I am not sure whether to mention this, but I re-
member being startled at the time, and maybe
you will be too: one of the articles he
republished in his book bore the title ‘Science
Fiction – Sex for Ever: A New Cybernetic Project
called Interfuck’ (Wells, 1970, 140-143), which
proposed ‘the development of a group of sys-
tems for the two-way transmission of sensory-
sexual information’, based on the apparatus
developed by Masters and Johnson for measur-
ing the human sexual response. It contained
the laconic remark ‘the project is difficult to
name in English,’ although Oliver Wells seems
to have had no trouble with this. It seems to
me a case of boundary crossing worth drawing
to your attention. I also owe to Wells a pithy
formula, ‘the brain computes the world’, which
summed up admirably a causal theory of per-
ception that still holds water today.
Artorga engaged in a collective effort to build
a self-reproducing machine, based on some ge-
netic work by Lionel Penrose. In the Penrose
archive at University College London, I recently
came across an interview with Wells, in French,

in the journal Science et Vie, in which the
interviewer, Gerald Messadié, expressed his ad-
miration for the systems work going on in the
English-speaking world and concluded rather
enviously:
‘There is today no creative mind which does
not direct all its wishes to a profound re-
newal of all the ideas with which we live. In-
numerable original works are sleeping in the
files of scientists and technologists. It is per-
haps Artorga that is preparing the synthesis
and the reorganization that are necessary, a
veritable work of the Encyclopedists [quite
a compliment for a Frenchman]. It only re-
mains for France to join in’ (Messadié, 1961).
In view of the plethora of systems literature to
which Gerald Midgley referred the other day, it
would seem that this work is as urgent as ever.
In my Presidential address, which I entitled
‘Science and System: on the Unity and Diversity
of Scientific Theory’, I commented on the change
from ‘theory’ to ‘research’ in the name of the soci-
ety, which seemed to me to mark a becoming
modesty. A theory, as I pointed out, is really a
way of looking at things – theoros in Greek meant
an official observer, who accompanied people to
the consultation of oracles or to competition in
the regional games, to ensure that things were
done in proper order and reported correctly. So
a theory is not just any old way of looking, but
one which carries some gravitas and will stand
against challenge. A general theory would be a

way of looking at many things, perhaps at all
things, in a similar way.
The further transition from ‘theory’ to ‘science’
makes a stronger claim. What rendered all those
conjectured isomorphisms suspect was that theo-
retical possibilities do not always map onto phys-
ical actualities. Natural systems come into being
as they do, with the contingency of evolutionary
accidents and pressures – many niches remain
unfilled, so we cannot assume totality or even
generality. It was a good move on the part of
the International Society for the Systems Sciences
to drop the ‘General’ of the Society for General
Systems Research.
Already in my dissertation, I was stressing the
need for the theoretician to accompany and ani-
mate the theory, which could I suppose be taken
as a version of the view that the observer has to
be considered along with what is observed. That
view, however, has to be handled with care. That
there might be a theory of theories, a science of
science, seemed obvious to me, but that did not
mean that there was anything wrong or naive in
trying for a science free of observer bias, and in-
deed that is a condition of success in most of
the physical, as opposed to the social or human,
sciences. The essential conditions for a science,
it still seems to me, are three:
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(1) Object constancy across knowing subjects,
including agreed nomenclature (this means
being surewe are talking about the same thing);
(2) Replicable observations and predictions, sub-
ject to common reporting standards (thismeans
looking at the same elements of theworld in the
same way); and
(3) Theoretical consistency, including to the
extent possible, simplicity and plausibility
(this means arguing openly and convincingly
in the face of doubt or criticism).
These last conditions are sometimes definitive.
One notable case for the test of simplicity is the
switch from the Ptolemaic to the Copernican
account of the solar system. As I pointed out in
an earlier paper (Caws, 1963), the advent of com-
puters would have made predictions according
to the Ptolemaic view quite feasible, but the
simpler Copernican picture was easier to visua-
lize and its predictions quicker to compute. A
contemporary challenge to the test of plausibility
is presented by Big Bang theory and particularly
by inflationary cosmology, which make extra-
ordinary claims on belief in matters of time and
causality.
PART 2

There followed a series of changes in my field of
work, although not all at the same time. One of
them was an existentialist turn, thanks to
students in Kansas who persuaded me to read
Kierkegaard and Sartre with them, in spite of
my appointment in logic and the philosophy of
science. Later, there was a structuralist turn,
thanks to the French (their answer to Messadié?).
In the summer of 1966, at the conference center of
Cerisy-la-Salle in Normandy, I met a young
French scholar of whom I inquired what was
going on of interest in French philosophy at the
time. Knowing that I taught philosophy in the
United States, she tried to pin me down: ‘was I
a positivist?’ ‘No’, I said. ‘A Marxist, then?’ ‘Not
that either’. ‘So you must be a structuralist’,
she said. I did not know what that was, not at
any rate as a philosophical position. But the inter-
esting philosophical work is not going on in
philosophy, she said – you should talk to the
anthropologists and the literary critics and the
psychoanalysts and the linguists.
I proceeded to do just this, spending some-
thing like a decade in preparation for my book
on structuralism that came out some time later
(Caws, 1989, 2000). In the meantime I published
in the technical journals of all these fields, with
the exception of linguistics. Does that make me
then a jack of all trades? I suppose I may be said
to have earned my union card with my work on
Sartre, if not on structuralism itself, but just as
in the case of teaching general science I have
never regretted my apprenticeship in those other
fields. What they all had in common was

starting, not from the objects under investigation,
but from the minds that recognized, learned,
appreciated and, in the end, created those objects.
As I put it in Yorick, structuralism ‘is a view of
mind as a structuring agent, which puts together
a world of thought comparable in its complexity
to the world of experience’ (Caws, 1993, 110).
Reducing all this to the point now at issue, it
represented a shift from an interest in systems
to an interest in structures. This distinction is of
critical importance. As I see it, systems are sets
of independently existing elements in (func-
tional) relations with one another, whereas struc-
tures (leaving aside the everyday meaning of the
term as referring to physical buildings) are sets of
relations, whose elements come into being and
are defined by the very relations that determine
them. Systemic relations are embodied; structural
ones are intended. And it is important to know
what ‘relation’ means. There are relations (a) that
are straightforwardly embodied in physical
objects, (b) that are defined as ordered pairs of
elements, physical or otherwise (mapping or not
onto classes of type a) or (c) that are established
by intentionality and apposition. This last class
is by far the most interesting and important.
By intentionality, I mean the capacity human
beings have of directing thought towards chosen
objects (attention is the special case in which the
objects are presented; intention when they are
more freely chosen or even created), and by ap-
position I mean the companion capacity to take
any two such objects and hold them in relation
to one another. Obvious cases are naming, and

521 (2015)
DOI: 10.1002/sres.2353
518 Peter Caws
translating, and establishing hypothetical rela-
tions between given or chosen elements. Inten-
tional relations require a subject and can only be
sustained as long as the subject continues to
intend them.
This clearly gives them a status quite different
from the embodied relations of my class (a). For
the latter, a reasonable postulate is what I call
‘the realist hypothesis’, namely, the hypothesis
that there really are things in the world related
in just those ways, and that they are and remain
related in those ways, whether we pay any atten-
tion to them or not. But intentional relations do
not hold unless someone is paying attention to
them. Popper (1972) to the contrary notwith-
standing, there is no World III in which objective
problems exist, waiting to be solved. At the same
time, if I am not thinking about one of these prob-
lems, it is very likely that someone else is (this is a
general point, of wide application, which I do not
have time to develop) so the appropriate hypoth-
esis is what I call the ‘other-minds (or co-inten-
tional) hypothesis’. These hypotheses underlie
different modes of being of the objects of the

sciences, perceptual/physical versus intentional/
cultural.
So structural elements are defined as relational
and constitute whole domains of the objects that
are of the most interest to us – kinship, language,
law, literature, theory, etc. – and, I would claim,
the domains of mathematics and theology also.
A quick example of the sort of situation that
may arise: the Greek Simonides set a riddle,
‘The son is the father of his father’, the solution
to which is the observation that the father does
not come into being as a father until the son
brings him into being as such by being born to
him.
The great difference then is between relations
as embodied in physical systems and relations
as components of intentional structures that
may or may not correspond to physical systems.
The natural sciences deal with systems, what I
call the human sciences with structures. But
structures can be superimposed upon systems,
and this regularly happens when objects and
their relations are named and made elements of
theoretical structures having empirical reference.
The natural sciences deal with objects that would
be as they are, whether or not anyone takes any
interest in them, and events that would happen
anyway once the relevant conditions are realized,
but the human sciences deal with objects that
come into being only through human intention
and intervention, events that are brought about
by human action.

Natural processes without contrivance do not
have ends but do have consequences. Natural
processes contrived for human ends (which we
call technology) lead in principle to desirable
consequences – but may also have undesirable
ones (often lumped under the catchall designa-
tion of ‘unintended consequences’). Human pro-
cesses that lead to action (always on the part of
individuals) are normally intended to have desir-
able consequences, but whether they do so
depends on the good will, the knowledge and
the wisdom of those individuals. A lot of work
remains to be done on such human systems.
Having introduced human agents, I should
perhaps make one further remark about putting
the observer into the system. The problem is this:
suppose system S to be observed by observer O,
O being external to the system under observation.
Bringing the two together, we have the more
inclusive system [S+O]. This in turn becomes an
object for theoretical reflection on the part of a sec-
ond observer, O′, who once again is external to
the system, yielding the new system [[S+O]+O′],
to be reflected on by a third observer, Oʺ, and so
on. This is a classic problem, going back at least
to the Hegelian System, which was supposed to
encompass everything – except, as Kierkegaard
pointed out, there was no room in it for Hegel him-
self. If we are to grasp the system, we have to have
a point of view outside it fromwhich to do so. The
real advantage of the second-order cybernetic
strategy comes into play when the observer is also
an agent, but the distinction between the two roles
must be kept clear.

PART 3
What light can the concept of systems throw on
our knowledge of the universe and its worlds?
This again is a critical distinction: the concept of
‘world’ (and there are many worlds) is essentially
521 (2015)
DOI: 10.1002/sres.2353
related to the human, that of the universe (of
which there is only one, theories of the multiverse
to the contrary notwithstanding) transcends
human interests, even if human theorizing has
the ambition of encompassing it. Systems thinking
insists, then, that we regard worlds and the
universe as thoroughly interrelated totalities,
every part being accessible from every part, and
the interactions of the parts being in principle intel-
ligible and predictable.
What are the risks of assuming tight isomor-
phisms between mathematical structures and
physical systems, for example, in cosmology
and quantum mechanics? If my colleagues in
the 1960s jumped to unwarranted conclusions,
this need not have meant that they were alto-
gether on the wrong track. Even if not all
theoretical relations are physically instantiated,

that is no reason not to look for those that are.
So the assumption is premature, but as a goal,
it is worthy. One of the virtues of general sys-
tems theory was and is its breaking down of
the partitions between the sciences that left
each busy in its own domain without talking
of the synergy their cross-fertilization could
generate.
The supplementing of systemic relations with
structural ones means not only stressing but also
exploiting the distinction between what I have
been calling the natural sciences and the human
sciences, recognizing that they have different
ontologies and different dynamics. The natural
sciences deal with physical objects that behave
according to laws discernible through studies of
their behavior, while the human sciences deal
with cultural objects that behave according to
the beliefs and intentions of human agents. One
cardinal principle that emerges from a consider-
ation of this distinction is that it is futile to try
to solve problems in the human sciences with
tools appropriate to the natural sciences, for
example, by attempting to settle ideological
differences with weapons of war (the converse
case is not so clear-cut, partly because the objects
governed by the natural sciences have them-
selves to be conceptualized and subjected to
measurement).
The great lesson here is to keep the natural and
human sciences in a collaborative tension with
one another, and to regard them, if you will, as
components of a larger system; to have both as-

pects openly in mind in all our work, but not to
confuse them with one another; and to have per-
meable boundaries between domains (gates, not
just fences). We should learn everything possible,
even from apparently competing disciplines.
And we should maintain an active theoretical
stance, not allowing technology – invaluable as
it is – to supersede the intimate and immediate
working of the mind. Theories require observers
(remember the theoros), but they may make them-
selves practically unnecessary by being embod-
ied in technology, and in this lies a practical
danger. Think, to take a banal but telling exam-
ple, of how it used to be necessary for clerks in
stores to be adept at mental arithmetic, whereas
now all that mind work is done by an automated
cash register. It is not that the mind of the cashier
is necessary to compute the customer’s change –
it is rather than computing the customer’s
change would be useful for the maintenance of
the mind of the cashier. The same point could
be made, mutatis mutandis, at all levels up to the
highest – an educated acquaintance with the rele-
vant theory is a prerequisite for the successful
solution of problems that arise.
Can systems thinking make for a better world?
In closing, I offer you a utopian, but nevertheless
realistic, thought: it would be better for everyone
if everyone thought about what would be better
for everyone. At current levels of technological
and social complexity that desideratum is not even
possible without some generally understood
theory of systems, that is, the practical challenge
of the present time.

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521 (2015)
DOI: 10.1002/sres.2353
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ANNALS OF FAMILY MEDICINE ✦
WWW.ANNFAMMED.ORG ✦ VOL. 2, NO. 6 ✦
NOVEMBER/DECEMBER 2004
576
576
The Biopsychosocial Model 25 Years Later:
Principles, Practice, and Scientifi c Inquiry
ABSTRACT
The biopsychosocial model is both a philosophy of clinical care
and a practical
clinical guide. Philosophically, it is a way of understanding how
suffering, disease,
and illness are affected by multiple levels of organization, from
the societal to the
molecular. At the practical level, it is a way of understanding
the patient’s subjec-
tive experience as an essential contributor to accurate diagnosis,
health outcomes,
and humane care. In this article, we defend the biopsychosocial
model as a nec-
essary contribution to the scientifi c clinical method, while
suggesting 3 clarifi ca-
tions: (1) the relationship between mental and physical aspects

of health is com-
plex—subjective experience depends on but is not reducible to
laws of physiology;
(2) models of circular causality must be tempered by linear
approximations when
considering treatment options; and (3) promoting a more
participatory clinician-
patient relationship is in keeping with current Western cultural
tendencies, but may
not be universally accepted. We propose a biopsychosocial-
oriented clinical prac-
tice whose pillars include (1) self-awareness; (2) active
cultivation of trust; (3) an
emotional style characterized by empathic curiosity; (4) self-
calibration as a way to
reduce bias; (5) educating the emotions to assist with diagnosis
and forming thera-
peutic relationships; (6) using informed intuition; and (7)
communicating clinical
evidence to foster dialogue, not just the mechanical application
of protocol. In con-
clusion, the value of the biopsychosocial model has not been in
the discovery of
new scientifi c laws, as the term “new paradigm” would suggest,
but rather in guid-
ing parsimonious application of medical knowledge to the needs
of each patient.
Ann Fam Med 2004;2:576-582. DOI: 10.1370/afm.245.
GEORGE ENGEL’S LEGACY
The late George Engel believed that to understand and respond
adequately to patients’ suffering—and to give them a sense of
being understood—clinicians must attend simultaneously to the
biologi-

cal, psychological, and social dimensions of illness. He offered
a holistic
alternative to the prevailing biomedical model that had
dominated indus-
trialized societies since the mid-20th century.1 His new model
came to be
known as the biopsychosocial model. He formulated his model
at a time
when science itself was evolving from an exclusively analytic,
reductionis-
tic, and specialized endeavor to become more contextual and
cross-disci-
plinary.2-4 Engel did not deny that the mainstream of
biomedical research
had fostered important advances in medicine, but he criticized
its exces-
sively narrow (biomedical) focus for leading clinicians to
regard patients
as objects and for ignoring the possibility that the subjective
experience of
the patient was amenable to scientifi c study. Engel championed
his ideas
not only as a scientifi c proposal, but also as a fundamental
ideology that
tried to reverse the dehumanization of medicine and
disempowerment of
patients (Table 1). His model struck a resonant chord with those
sectors of
the medical profession that wished to bring more empathy and
compassion
into medical practice.
In this article we critically examine and update 3 areas in which
the
biopsychosocial model was offered as a “new medical
paradigm”5,6: (1) a

Francesc Borrell-Carrió, MD1
Anthony L. Suchman MD2,3
Ronald M. Epstein MD4
1Department of Medicine, University of
Barcelona, CAP Cornellà, Catalonian
Institute of Health (ICS), Cornellà de
Llobregat, Spain
2Relationship Centered Health Care,
Rochester, NY
3Department of Medicine, University of
Rochester School of Medicine and Dentistry,
Rochester, NY
4Department of Family Medicine,
University of Rochester School of Medicine
and Dentistry, Rochester, NY
CORRESPONDING AUTHOR
Francesc Borrell-Carrió, MD
Department of Medicine
University of Barcelona
CAP Cornellà, Catalonian Institute of
Health (ICS)
C/Bellaterra 39
08940 Cornellà de Llobregat, Spain
[email protected]

577
577
BIOPSYCHOSOCIAL MODEL 25 YEARS LATER
world view that would include the patient’s subjective
experience alongside objective biomedical data, (2) a
model of causation that would be more comprehensive
and naturalistic than simple linear reductionist models,
and (3) a perspective on the patient-clinician relation-
ship that would accord more power to the patient in
the clinical process and transform the patient’s role
from passive object of investigation to the subject and
protagonist of the clinical act. We will also explore the
interface between the biopsychosocial model and evi-
dence-based medicine.
DUALISM, REDUCTIONISM,
AND THE DETACHED OBSERVER
In advancing the biopsychosocial model, Engel was
responding to 3 main strands in medical thinking that
he believed were responsible for dehumanizing care.
First, he criticized the dualistic nature of the biomedi-
cal model, with its separation of body and mind (which
is popularly, but perhaps inaccurately, traced to Des-
cartes).7,8 This conceptualization (further discussed in
the supplemental appendix, available online at http://

www.annfammed.org/cgi/content/full/2/6/576/
DC1) included an implicit privileging of the
former as more “real” and therefore more worthy
of a scientifi c clinician’s attention. Engel rejected this
view for encouraging physicians to maintain a strict
separation between the body-as-machine and the nar-
rative biography and emotions of the person—to focus
on the disease to the exclusion of the person who
was suffering—without building bridges between the
two realms. His research in psychosomatics pointed
toward a more integrative view, showing that fear, rage,
neglect, and attachment had physiologic and develop-
mental effects on the whole organism.
Second, Engel criticized the excessively materialis-
tic and reductionistic orientation
of medical thinking. According
to these principles, anything that
could not be objectively verifi ed
and explained at the level of cel-
lular and molecular processes was
ignored or devalued. The main
focus of this criticism—a cold,
impersonal, technical, biomedi-
cally-oriented style of clinical
practice—may not have been
so much a matter of underlying
philosophy, but discomfort with
practice that neglected the human
dimension of suffering. His semi-
nal 1980 article on the clinical
application of the biopsychoso-
cial model5 examines the case of a man with chest pain

whose arrhythmia was precipitated by a lack of caring
on the part of his treating physician.
The third element was the infl uence of the observer
on the observed. Engel understood that one cannot
understand a system from the inside without disturbing
the system in some way; in other words, in the human
dimension, as in the world of particle physics, one can-
not assume a stance of pure objectivity. In that way,
Engel provided a rationale for including the human
dimension of the physician and the patient as a legiti-
mate focus for scientifi c study.
Engel’s perspective is contrasted with a so-called
monistic or reductionistic view, in which all phenom-
ena could be reduced to smaller parts and understood
as molecular interactions. Nor did he endorse a holis-
tic-energetic view, many of whose adherents espouse
a biopsychosocial philosophy; these views hold that
all physical phenomena are ephemeral and control-
lable by the manipulation of healing energies. Rather,
in embracing Systems Theory,2 Engel recognized that
mental and social phenomena depended upon but
could not necessarily be reduced to (ie, explained in
terms of) more basic physical phenomena given our
current state of knowledge. He endorsed what would
now be considered a complexity view,9 in which differ-
ent levels of the biopsychosocial hierarchy could inter-
act, but the rules of interaction might not be directly
derived from the rules of the higher and lower rungs
of the biopsychosocial ladder. Rather, they would be
considered emergent properties that would be highly
dependent on the persons involved and the initial con-
ditions with which they were presented, much as large
weather patterns can depend on initial conditions and
small infl uences.9 This perspective has guided decades

of research seeking to elucidate the nature of these
interactions.
Table 1. Engel’s Critique of Biomedicine
1. A biochemical alteration does not translate directly into an
illness. The appearance of illness
results from the interaction of diverse causal factors, including
those at the molecular, individ-
ual, and social levels. And the converse, psychological
alterations may, under certain circum-
stances, manifest as illnesses or forms of suffering that
constitute health problems, including,
at times, biochemical correlates
2. The presence of a biological derangement does not shed light
on the meaning of the symp-
toms to the patient, nor does it necessarily infer the attitudes
and skills that the clinician must
have to gather information and process it well
3. Psychosocial variables are more important determinants of
susceptibility, severity, and course of
illness than had been previously appreciated by those who
maintain a biomedical view of illness
4. Adopting a sick role is not necessarily associated with the
presence of a biological derangement
5. The success of the most biological of treatments is infl
uenced by psychosocial factors, for
example, the so-called placebo effect
6. The patient-clinician relationship infl uences medical
outcomes, even if only because of its infl u-
ence on adherence to a chosen treatment

7. Unlike inanimate subjects of scientifi c scrutiny, patients are
profoundly infl uenced by the way in
which they are studied, and the scientists engaged in the study
are infl uenced by their subjects
578
COMPLEXITY SCIENCE: CIRCULAR
AND STRUCTURAL CAUSALITY
Engel objected to a linear cause-effect model to
describe clinical phenomena. Clinical reality is far more
complex. For example, although genetics may have
a role in causing schizophrenia, no clinician would
ignore the sociologic factors that might unleash or con-
tain the manifestations of the illness.
Complexity and Causality
Few morbid conditions could be interpreted as being
of the nature “one microbe, one illness”; rather, there
are usually multiple interacting causes and contributing
factors. Thus, obesity leads to both diabetes and arthri-
tis; both obesity and arthritis limit exercise capacity,
adversely affecting blood pressure and cholesterol lev-
els; and all of the above, except perhaps arthritis, con-
tribute to both stroke and coronary artery disease. Some
of the effects (depression after a heart attack or stroke)

can then become causal (greater likelihood of a second
similar event). Similar observations can be made about
predictors of relapse in schizophrenia. These obser-
vations set the stage for models of circular causality,
which describes how a series of feedback loops sustain
a specifi c pattern of behavior over time.10-13 Complex-
ity science is an attempt to understand these complex
recursive and emergent properties of systems14,15 and to
fi nd interrelated proximal causes that might be changed
with the right set of interventions (family support and
medications for schizophrenia; depression screening and
cholesterol level reduction after a heart attack).
Structural Causality
In contrast to the circular view, structural causality
describes a hierarchy of unidirectional cause-effect
relationships—necessary causes, precipitants, sustaining
forces, and associated events.16 For instance, a neces-
sary cause for tuberculosis is a mycobacterium, precipi-
tants can be a low body temperature, and a sustaining
force a low caloric intake. Complexity science can
facilitate understanding of a clinical situation, but most
of the time a structural model is what guides practical
action. For example, if we think that Mr. J is hyperten-
sive because he consumes too much salt, has a stress-
ful job, poor social supports, and an overresponsible
personality type, following a circular causal model,
possibly all of these factors are truly contributory to his
high blood pressure. But, when we suggest to him that
he take an antihypertensive medication, or that he con-
sume less salt, or that he take a stress-reduction course,
or that he see a psychotherapist to reduce his sense of
guilt, we are creating an implicit hierarchy of causes:
Which cause has the greatest likely contribution to his
high blood pressure? Which would be most responsive

to our actions? What is the added value of this action,
after having done others? Which strategy will give the
greatest result with the least harm and with the least
expenditure of resources?
Interpretations, Language, and Causality
Causal attributions have the power to create reality and
transform the patient’s view of his/her own world.17 A
physician who listens well might agree when a patient
worries that a family argument precipitated a myo-
cardial infarction; although this interpretation may
have meaning to the patient, it is inadequate as a total
explanation of why the patient suffered a myocardial
infarction. The attribution of causality can be used to
blame the patient for his or her illness (“If only he had
not smoked so much.…”), and also may have the power
of suggestion and might actually worsen the patient’s
condition (“Every time there is a fi ght, your dizziness
worsens, don’t you see?”).
TOWARD A RELATIONSHIP-CENTERED
MODEL
Power and Emotions in the Clinical Relationship
Patient-centered, relationship-centered, and client-cen-
tered approaches18-24 propose that arriving at a correct
biomedical diagnosis is only part of the clinician’s task;
they also insist on interpreting illness and health from
an intersubjective perspective by giving the patient
space to articulate his or her concerns, fi nding out
about the patient’s expectations, and exhorting the
health professional to show the patient a human face.
These approaches represent movement toward an egali-
tarian relationship in which the clinician is aware of
and careful with his or her use of power.
This “dialogic” model suggests that the reality of

each person is not just interpreted by the physician,
but actually created and recreated through dialogue25-31;
individual identities are constructed in and maintained
through social interaction.32 The physician’s task is to
come to some shared understanding of the patient’s
narrative with the patient. Such understanding does not
imply uncritical acceptance of whatever the patient
believes or hypothesizes, but neither does it allow for
the uncritical negation of the patient’s perspective, as
so frequently occurs, for example, when patients com-
plain of symptoms that physicians cannot explain.33,34
The patient’s story is simultaneously a statement about
the patient’s life, the here-and-now enactment of his
life trajectory, and data upon which to formulate a
diagnosis and treatment plan.
Underlying the analysis of power in the clinical
relationship is the issue of how the clinician handles the
579
strong emotions that characterize everyday practice. On
the one hand, there is a reactive clinical style, in which
the clinician reacts swiftly to expressions of hostility or
distrust with denial or suppression. In contrast, a proac-
tive clinical style, characterized by a mindful openness to
experience, might lead the clinician to accept the patient’s
expressions with aplomb, using the negative feelings to

strengthen the patient-clinician relationship.35 The clini-
cian must acknowledge and then transcend the tendency
to label patients as “those with whom I get along well”
or “diffi cult patients.” By removing this set of judgments,
true empathy can devolve from a sense of solidarity with
the patient and respect for his or her humanity, leading
to tolerance and understanding.18 Thus, in addition to the
moral imperative to treat the patient as a person, there is
a corresponding imperative for the physician to care for
and deepen knowledge of himself or herself.35,36 Without
a suffi cient degree of self-understanding, it is easy for the
physician to confuse empathy with the projection of his
or her needs onto the patient.
Implications for Autonomy
Most patients desire more information from their
physicians, fewer desire direct participation in clinical
decisions, and very few want to make important deci-
sions without the physician’s advice and consultation
with their family members.37-40 This does not mean that
patients wish to be passive, even the seriously ill and the
elderly.41 In some cases, however, clinicians unwittingly
impose autonomy on patients.19,42,43 Making a reluctant
patient assume too much of the burden of knowledge
about an illness and decision making, without the advice
from the physician and support from his or her family,
can leave the patient feeling abandoned and deprived
of the physician’s judgment and expertise.42 The ideal,
then, might be “autonomy in relation”—an informed
choice supported by a caring relationship.19 The clini-
cian can offer the patient the option of autonomy41
while considering the possibility that the patient might
not want to know the whole truth and wish to exercise
the right to delegate decisions to family members.40,44

The Social Milieu
There is an ecological dimension of each encounter—it
is not just between patient and physician, but rather an
expression of social norms.45 Sometimes clinicians face
a dilemma: can or should a private clinical relationship
between patient and physician be a vehicle for social
transformation? Or, should the relationship honor and
conform to the cultural norms of patients?19 Our view is
that adaptation normally should occur before transfor-
mation—the physician must fi rst understand and accom-
modate to the patient’s values and cultural norms before
trying to effect change. Otherwise, the relationship
becomes a political battleground and the focus of a pro-
cess to which the patient has not consented and may not
desire. This debate, however, becomes much more diffi -
cult in situations in which patients have suffered abuse—
for example domestic violence or victims of torture.46
In those cases, not trying to remedy the social injustices
that resulted in the patient seeking care may interfere
with the formation of a trusting relationship. The physi-
cian may be tempted to effect a social transformation in
these cases, for example, to advise the patient to leave an
abusive situation, even though the patient may state that
she only wants care for the bruises. Premature advice
may interfere with enabling the patient to be the agent
of change, however. Stopping short of attempting to
transform social relationships until the patient has given
consent should not be interpreted as indifference to,
acceptance of, or complicity in such situations; rather, it
should be viewed as a prudent course of action that will
ultimately be validating and empowering.
Caring, Paternalism, and Empathy
Taking Engel’s view, perhaps it is not paternalism that is

the problem but practicing as a cold technician rather
than a caring healer.47,48 The physician who sees his or
her role as nothing more than a technical adviser can
regard empathy as a useless effort that has no infl uence
on clinical decisions, or, worse, a set of linguistic tricks
to get the patient to comply with treatment. Because
it is entirely possible to advocate for shared decision
making without challenging the notion of the cold
technician, we propose to move the emphasis to an
approach that emphasizes human warmth, understand-
ing, generosity, and caring.
THE BIOPSYCHOSOCIAL MODEL
AND RELATIONSHIP-CENTERED CARE
The practical application of the biopsychosocial model,
which we will call biopsychosocially oriented clinical prac-
tice does not necessarily evolve from the constructs of
interactional dualism or circular causality. Rather, it may
be that the content and emotions that constitute the
clinician’s relationship with the patient are the funda-
mental principles of biopsychosocial-oriented clinical
practice, which then inform the manner in which the
physician exercises his or her power. The models of
relationship that have tended to appear in the medical
literature, with a few notable exceptions,19 have perhaps
focused too much on an analysis of power and too little
on the underlying emotional climate of the clinical
relationship. For this reason, we suggest a reformulation
of some of the basic principles of the biopsychosocial
model according to the emotional tone that engraves the
relationship with such characteristics as caring, trustwor-

580
thiness, and openness.49,50 Some principles of biopsycho-
social-oriented clinical practice are outlined below.
Calibrating the Physician
The biopsychosocial model calls for expanding the
number and types of habits to be consciously learned
and objectively monitored to maintain the centrality of
the patient.51 The physician is in some ways like a musi-
cal instrument that needs to be calibrated, tuned, and
adjusted to perform adequately.36 The physician’s skills
should be judged on their ability to produce greater
health or to relieve the patient’s suffering—whether they
include creating an adequate emotional tone, gather-
ing an accurate history, or distinguishing between what
the patient needs and what the patient says he or she
wants. In that regard, a clinical skill includes the ethical
mandate not only to fi nd out what concerns the patient,
but to bring the physician’s agenda to the table and infl u-
ence the patient’s behavior. Sometimes doing so may
include uncovering psychosocial correlates of otherwise
unexplained somatic symptoms (such as ongoing abuse
or alcoholism) to break the cycle of medicalization and
iatrogenesis.33 To abandon this obligation, in our view, is
breaking an implicit social contract between physicians
and society. This deliberative and sometimes frankly
physician-centered approach has its perils, however.
The physician must be capable of an ongoing self-audit
simply because his or her performance is never the same
from moment to moment. Weick and Sutcliffe52 regard
this constant vigilance as a fundamental requirement for

professions that require high reliability in the face of
unexpected events. Mindfulness—the habits of attentive
observation, critical curiosity, informed fl exibility, and
presence—underlies the physician’s ability to self-moni-
tor, be vigilant, and respond with compassion.35,53,54
Creating Trust
The expert clinician considers explicitly, as a core skill,
the achievement in the encounter of an emotional tone
conducive to a therapeutic relationship. For that reason,
all consultations might be judged on the basis of cordial-
ity, optimism, genuineness, and good humor. By receiv-
ing a hostile patient with respect,55 it clarifi es for the cli-
nician that the patient’s emotions are the patient’s—and
not the physician’s—and also sets the stage for the
patient to refl ect as well. Similarly, the physician must
know how to recognize and when to express his or her
own emotions, sometimes setting limits and boundaries
in the interest of preserving a functional relationship.
Cultivating Curiosity
The next step in the application of clinical evidence
to medical care is the cultivation of curiosity. Thus,
cultivated naïvete56 might be considered one of the
fundamental habits characteristic of expert practitioners.
Another aspect of this emotional tone is an empathic
curiosity about the patient as person. Empathic curiosity
allows the clinician to maintain an open mind and not
to consider that any case is ever closed. If the patient
does not surprise us today, perhaps he or she will
tomorrow. We have described this capacity using the
term, beginner’s mind.35,57 It is the capacity for expecting
the unexpected, just as if the physician were another cli-
nician seeing the patient for the fi rst time. There is also
an ethical component of this emotional tone—there are

no “good” or “bad” patients, nor are there “interesting”
and “boring” diseases. Patients should not have to legiti-
mize their suffering by describing illnesses that make
the clinician feel comfortable or confi dent.58
Recognizing Bias
The grounding of medical decisions based on scientifi c
evidence while also integrating the clinician’s professional
experience is now a well-accepted tenet of the founders
of the evidence-based medicine movement.59 The method
for incorporation of experience, however, has been less
well described than the method for judging the quality of
scientifi c evidence. For example, clinicians should learn
how their decisions might be biased by the race and sex
of the patient, among other factors,51 and also the ten-
dency to close the case prematurely to rid oneself of the
burden of attempting to solve complex problems.60
Educating the Emotions
There are methods for emotional education, just as
there are for learning new knowledge and skills.35
Tolerance of uncertainty, for example, is amenable to
observation and calibration—making decisions in the
absence of complete information is a characteristic of
an expert practitioner, in contrast to the technician
who views his role as simply following protocols.
Using Informed Intuition
The role of intuition is central. Just as Polanyi and
Schön maintain that professional competence is based
in tacit, rather than explicit, knowledge,61,62 expertise
often is manifest in insights that are diffi cult to track
on a strictly cognitive level. If a clinician, encountering
a situation in which he normally would use a particu-
lar treatment, has the intuition, for a reason that has

not yet become clear, that treatment might not be the
best for this particular patient, we suggest, rather than
considering it a feeling from nowhere that might be dis-
carded, perhaps the intuition can later be traced to a set
of concrete observations about the patient that were not
easy for the clinician to describe at the time. Because
these observations often are manifest only when cases
are reviewed after the fact does not diminish the ethical
581
obligation that the clinician use all of his or her capa-
bilities, not only those which can be readily explained.
Communicating Clinical Evidence
Evidence should be communicated in terms the patient
can understand, in small digestible pieces, at a rate
at which it can be assimilated. Information overload
may have two effects—reduction in comprehension
and increasing the emotional distance between physi-
cian and patient. Communication of clinical evidence
should foster understanding, not simply answers.63
FURTHER DEVELOPMENT OF
THE BIOPSYCHOSOCIAL MODEL
George Engel formulated the biopsychosocial model as
a dynamic, interactional, but dualistic view of human
experience in which there is mutual infl uence of mind

and body. We add to that model the need to balance a
circular model of causality with the need to make linear
approximations (especially in planning treatments) and
the need to change the clinician’s stance from objective
detachment to refl ective participation, thus infusing
care with greater warmth and caring. The biopsycho-
social model was not so much a paradigm shift—in the
sense of a crisis of the scientifi c method in medicine
or the elaboration of new scientifi c laws—as it was an
expanded (but nonetheless parsimonious) application of
existing knowledge to the needs of each patient.
In the 25 years that have elapsed since Engel fi rst
proposed the biopsychosocial model, two new intellec-
tual trends have emerged that could make it even more
robust. First, we can move beyond the problematic
issue of mind-body duality by recognizing that knowl-
edge is socially constructed. To some extent, such
categories as “mind” or “body” are of our own creation.
They are useful to the extent that they focus our think-
ing and action in helpful ways (eg, they contribute to
health, well-being, and effi cient use of resources), but
when taken too literally, they can also entrap and limit
us by creating boundaries that need not exist. By main-
taining what William James called “fragile” categories,64
we can alter or dispose of categories as new evidence
accumulates and when there is a need to engage in fl ex-
ible, out-of-the-box thinking.
Second, we can move beyond the multidimensional
and multifactorial linear thinking to consider complex-
ity theory as a more adequate model for understanding
causality, dualism, and participation in care. Complex-
ity theory shows how, in open systems, it is often
impossible to know all of the contributors to and infl u-
ences on particular health outcomes. By describing the

ways in which systems tend to self-organize, it provides
guideposts to inform the clinician’s actions. It also buf-
fers the tendency to impose unrealistic expectations
that one can know and control all of these contributors
and infl uences.65
George Engel’s most enduring contribution was
to broaden the scope of the clinician’s gaze. His bio-
psychosocial model was a call to change our way of
understanding the patient and to expand the domain
of medical knowledge to address the needs of each
patient. It is perhaps the transformation of the way
illness, suffering, and healing are viewed that may be
Engel’s most durable contribution.
To read or post commentaries in response to this article, see it
online at http://www.annfammed.org/cgi/content/full/2/6/576.
Key words: Biopsychosocial model; clinical practice patterns;
personal
autonomy; empathy; communication; education
Submitted September 25, 2003; submitted, revised, January 28,
2004;
accepted February 10, 2004.
Acknowledgments: The following people have provided
important cri-
tiques of this article. We thankfully acknowledge their
contributions, but
do not infer that they take responsibility for the content of the
article:
Drs. Rogelio Altisent, Lucy M. Candib, Jordi Cebrià, José
Corrales, Blas
Coscollar, Javier García-Campayo, Salvador García-Sánchez,

Diego Gracia,
Maria León, Susan McDaniel, Fernando Orozco, Vicente Ortún,
Timothy
Quill, Roger Ruiz, Jorge Tizón, and Lyman Wynne.
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