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Published in final edited form as: Health Psychol. 2013 May;32(5):597–601. doi: 10.1037/a0031197

Three Strategies for Bridging Different Levels of Analysis and Embracing the Biopsychosocial Model

Jerry Suls 1, David S Krantz 2, Geoffrey C Williams 3
PMCID: PMC8634694  NIHMSID: NIHMS1756706  PMID: 23646844

Abstract

The five review articles in this special issue describe the progress that has been made forging links between personality and social psychological theories, methods, and results with biological, social, and cultural factors related to physical health. However, many efforts have fallen short of the goals of the biopsychosocial model. The rationale and description of 3 strategies to achieve a fuller integration across different levels of analysis are highlighted: (a) more cross-disciplinary research collaborations and training; (b) systematic efforts to make research and theory more clinically relevant; and (c) striving for more representative samples, settings, and outcomes.

Keywords: biopsychosocial model, health psychology, behavioral medicine, social psychology, personality psychology

The biopsychosocial model proposes that biological, psychological, social, and structural processes operate in a matrix of nested and inextricably connected subsystems that influence all aspects of mental and physical health. Engel (1977) formally articulated this view as a challenge to the traditional biomedical model in which biological/physiological processes were assumed to be sufficient to explain disease and its treatment. Engel’s idea was not entirely new; in the 1850s, Virchow, the father of cell theory, recognized the importance of social conditions for disease and proclaimed medicine was a social science.

In contrast with Engel’s (1977) formulation, recent discoveries in molecular biology continue to skew modern medicine’s perspective toward the traditional biomedical approach. One example is the pursuit of developing personalized drugs targeted to an individual’s genomic profile—unique and often expensive remedies—although whether this enterprise will be broadly applicable across populations remains unclear. Miracle drugs are only effective as long as patients take them. Medication use is affected by the patient’s emotions, self-regulation skills, by how their practitioner supports them, and the patients’ perceived ability to pay for them—all things that are accounted for by the biopsychosocial, and not by the biomedical, model. For chronic diseases such as cancer and heart disease, special treatments and new devices may forestall death, but long-term survival and quality of life depend on behavioral lifestyle changes by the patient.

Reluctance on the part of mainstream medicine to adopt the biopsychosocial model is understandable because molecular biology is its hub science. However, some areas of social-health psychology surprisingly have yet to adopt the complex systems approach integral to the biopsychosocial model. An archival study of articles published in Health Psychology revealed that researchers rarely assessed or manipulated factors at more than one or two different levels of analysis (Suls & Rothman, 2004). Too frequently, studies about the effects of interpersonal or intergroup factors on health offer little more than “hand waving” to refer to biological or structural processes (in fairness, medical journals often engage in “hand waving” about psychological and social-personality psychological factors). Forging of in-depth connections across biological, social, and structural levels of analysis to understand the complexity of patients and disease has been less than optimal.

To encourage more bridging, we recommend the adoption of three strategies: (a) more cross-disciplinary research collaborations and training; (b) systematic efforts to make research and theory more clinically relevant; and (c) striving for more representative samples, settings, and outcomes. These three strategies are described in more detail in the next sections.

Multidisciplinary Research and the Need for Multidisciplinary Research Training in Health Psychology

Today’s most important health problems, especially those involving the prevention, etiology, treatment, and/or consequences of chronic disease, are complex and multifactorial (Pellmar & Eisenberg, 2000; Committee on Facilitating Interdisciplinary Research of National Academy of Science, 2005). These health problems often involve processes and mechanisms that are beyond the scope of any single discipline or are on the interface of two disciplines. For these reasons, it has become increasingly common in the biomedical sciences for these complex problems to be addressed by multidisciplinary research teams involving collaborations between researchers representing different fields (Nation Research Council, 2005).

As a subarea of psychology, health psychology capitalizes on the skills and knowledge that it can offer to address health problems (Matarazzo, 1980). However, the domain of health psychology overlaps with other disciplines. This overlap includes interactions of psychological processes with the biomedical sciences (e.g., medicine, physiology, molecular biology, neuroscience), with the social sciences (e.g., sociology, anthropology, economics), and even with the humanities and law (Swartz & Gottheil, 1991). It follows that a comprehensive scientific and clinical understanding of health and disease will involve elements across a broad range of systems levels, ranging from the genetic level to the societal level.

Consider, for example, two important areas addressed by articles in this issue: the role of affect and emotion in health (DeSteno, Kubzansky, & Gross, pp. 474–486), and applications of intergroup processes to understanding health disparities among ethnic groups (Major, Dovidio, & Berry-Mendes, pp, 514–524). A key element addressed by both articles is how intrapersonal (in the case of affect) or interpersonal (in the case of group relations) situations translate into health-impairing physiological processes. The authors of both articles explicitly acknowledge the need to capture physiological data. Further advances would be fostered by more research and training on the interface of psychology with the biomedical sciences that would allow the same level of detailed elucidation of the biological as the psychosocial processes.

Multidisciplinary teams of psychologists, neuroscientists, immunologists, and medical specialists in relevant clinical fields are more commonly conducting cutting edge research in our field. Many psychologists either lead, or are participants in, these multidisciplinary research teams (e.g., Cohen, Tyrrell, & Smith, 1991; Epel et al., 2006; Kiecolt-Glaser, Bane, Glaser, & Malarkey, 2003; Kop et al., 2005). Health psychology would also be strengthened by research that transcends the level of the individual and incorporates community-based and public health approaches to addressing health disparities and interactions with the health care system.

To understand how these social processes translate into disease, it is necessary to understand the neuroendocrine, biochemical, cardiovascular, and immune and genetic effects of stress. Research in personality/social psychology at the interpersonal level must also be informed of problems facing the health care system and public health. Social and personality psychologists can acquire this expertise and awareness with innovative interdisciplinary pre- and postdoctoral training.

Training models that foster a multidisciplinary mind-set and that provide essential cross-disciplinary training are needed to provide requisite research skills and background, and to provide investigators with the tools needed to conduct this research. Indeed, interdisciplinary training models in health psychology and behavioral medicine are actively promoted by the National Institutes of Health (NIH) in its training portfolio, and are represented by interdisciplinary training programs in areas on the behavioral—biomedical science interface (e.g., cardiovascular behavioral medicine, psychoneuroimmunology, aging, and cancer). Since the establishment of behavioral medicine (Schwartz & Weiss, 1978) and health psychology in the late 1970s (Matarazzo, 1980), research training models in these fields seek to provide new researchers with the skills to understand and collaborate with workers in the boundary areas between psychology and biomedicine (Pellmar & Eisenberg, 2000). The National Working Conference on Education and Training in Health Psychology was convened just after health psychology was established, and it called for the interdisciplinary training of health psychologists (Miller, 1983) in areas such as pathophysiology, public health, and the health care system.

Clinical Relevance

The need for a field of “health psychology” was stimulate because psychology researchers and clinicians recognized that the traditional biomedical model fell short of explaining many heal outcomes and limited our insight into public health policy and clinical practice. In proposing the biopsychosocial model, Engel (1977) challenged the health care field to broaden its approach because biomedicine could not account for the effect its own practitioners had on patient outcomes.

In the current issue of Health Psychology, there are summaries of five important areas of social psychological effects on patient welfare. Each review presents advances concerning social and psychological mediators and moderators to illuminate the psychosocial-pathophysiologic mechanisms that promote or undermine patient welfare.

Relevance to Clinical Care

Despite considerable progress, much remains to be done to make these advances relevant to clinical care. A major goal of current research policy (Tunis & Styer, 2003) is to encourage translational research, which is research that transforms scientific knowledge into tangible health benefits. However, much of this work does not readily translate to clinical practice or to policies that improve the lives of the patients and practitioners. Being clinically relevant means to apply what we have learned to create interventions that can be tested for efficacy, effectiveness, and implementation in diverse populations (Kessler & Glasgow, 2011; Tunis & Styer, 2003).

To accomplish this, researchers would need to measure a broader range of clinically relevant health outcomes, including quality of life for patients and practitioner, cost-effectiveness, as well as the physical health outcomes. For example, the importance of the links between stress, emotion, personality, and self-regulation with cardiovascular disease was made salient by the ground-breaking INTERHEART Study (Rosengren et al., 2004; Yusuf et al., 2004). This case control study of almost 25,000 people from 52 countries identified nine factors accounting for over 90% of first myocardial infarctions. Psychosocial factors, such as distress, personality, and unhealthy lifestyle, had an impact that was comparable to traditional risk factors such as cholesterol and blood pressure. Research (McGinnis & Foege, 1993) confirmed that 40% of early mortality and 70% of health care costs were accounted for by four unhealthy behaviors (Schroeder, 2007): tobacco use and exposure, physical inactivity, poor nutrition, and overuse of alcohol. It is important to apply what we know about self-regulation (Mann, Fujita, & de Ridder, in press; Ng et al., 2012,) to bring our theories and interventions to the bedside. This would involve conducting appropriately designed studies that assess physical, mental, quality of life, and cost outcomes, which can convince decision makers to make changes in the delivery of care.

The Behavior Change Consortium (Solomon & Kingston, 2002) represents an example of a NIH-funded effort for researchers to create interventions based on social and psychological theory to facilitate initial changes in those four unhealthy lifestyle behaviors. Subsequently, the Health Maintenance Consortium (Ory, Smith, Mier, & Wernicke, 2010) pursued a better understanding of maintenance of healthy behavior changes. Personality and social psychologists can help us understand how we can change practitioner behavior by examining clinically relevant outcomes whenever possible, and designing studies in a manner that decision makers can use. Clinical relevance is also enhanced when health psychologists report outcomes on multiple levels (e.g., psychological, physiological, and cost-effectiveness).

Close relationships also have been of interest to both practitioners and researchers. Pietromonaco, Uchino, and Dunkel Shetter (this issue, pp. 499–513) have formulated a theoretically and empirically based model of relationships in health care for primary care patients. We encourage further integration of this research with the work of other clinician-researchers active in practitioner—patient relationships (Street, Makoul, Arora, & Epstein, 2009). Another clinically relevant area personality and social psychologists can research is the medical interview. Investigations of “the medical encounter” would advance psychological theory and also have practical value. For example, Takemura, Atsumi, and Tsuda (2007) recently identified several interpersonal techniques that predict the amount of information gathered in real clinical encounters. These and related studies demonstrate how personality and social psychological approaches can identify what medical educators need to teach to improve the outcomes of care.

Overreliance on Convenience Samples, Nonrepresentative Settings, and Limited Range of Outcomes

Much of the theory and research that serves as the starting point for social-health psychologists has relied on convenience samples of young college students (although the review authors wisely focus on community samples and medical patients). Surveys 22 years apart (Sears, 1986; Henry, 2008) found 75% of the studies published in top social psychology journals employed college student samples. Prior to the 1960s, however, middle-aged adults more commonly served as subjects (Sears, 1986). Health psychologists recruit a larger proportion of their research participants from community or patient populations than do social psychologists. However, both health and personality—social psychologists rely too much on convenience samples. Often, these are obtained at colleges and universities, so, in addition to being younger, college students tend to be higher in socioeconomic status (SES), have greater cognitive aptitude, and have better physical health than the general population. Continued reliance on this thin slice of the population compromises the generalizability of results and also obscures relationships between variables at different levels of analysis.

Lack of sample representativeness also is connected to other features of experimentation in social-personality psychology—reliance on the laboratory, low impact manipulations, a narrow range of outcomes, and little assessment of changes over time. In some quarters, unrepresentativeness of situations and subjects are perceived to be strengths of experimental research because of the experimental control they provide. This “research philosophy” has been a longstanding one that partly originated from early leaders in the social psychology field. Leon Festinger (1953), one of the foremost experimental social psychologists of the 20th century, observed, “It matters not whether such a[n experimental] situation would ever be encountered in real life… In a laboratory, however, we can find out exactly how a certain variable affects behavior or attitudes under special, or ‘pure,’ conditions” (p. 139).1 Use of college student samples is also perceived to increase population “purity” by reducing variability and thereby maximizing the likelihood of capturing statistically significant results for variables that may have a low effect size.

Generalizability of findings is a particularly important issue in order to make their contributions relevant to the real world. In programmatic research that seeks application to the real world, the next logical step should be to test the same hypothesis in different kinds of samples. However, this is infrequent in social and personality psychology, perhaps because replication and assessing generalizability are not encouraged. (Physics, chemistry, and medicine value and encourage replication more!—see Madden, Easley, & Dunn, 1995; Mahoney, 1985; Neuliep & Crandall, 1990.) In addition, by tradition, the primary goal of this research was seeking general principles of behavior, and the assumption is that findings from college students contribute to knowledge about these general principles (Gergen, 1973). Because much of this research was viewed as fundamental or basic, and not applied, neither was there motivation to replicate the research in real-world settings. (This premise has softened in recent years.)

The assumption of generality from this research strategy seems to be taken on faith, but the evidence raises significant doubts (Peterson, 2001). Anderson, Lindsay, and Bushman (1999) compared effect sizes from laboratory and field studies of 38 research topics compiled in prior meta-analyses. They found a correlation of .73, which led them to conclude that “the psychological laboratory is doing well in terms of external validity” (Anderson et al., 1999, p. 8). A more recent and more comprehensive analysis, however, covered a wider range of topics. Mitchell (2012) also found that lab and field effects correlated at about .71, but differentiating by subfields, social psychology showed the lowest correlation (r = .53). Further, “twenty-one of 80 (26.3%) laboratory effects from social psychology changed signs between research setting” (p. 112). Peterson (2001) systematically compared results found with college students versus nonstudent (older) samples in the psychological literature and found the responses of college students were more homogeneous, with the potential to reduce the magnitude of differences or minimize relationships that actually exist among variables (see Steele & Southwick, 1985, for an example). These findings showing effects vary in homogeneity, magnitude, and direction (!) qualify as strong evidence that generalizing from research using college students and/or lab settings is not a sound practice.

Also consider that most laboratory studies conducted in a university setting involve brief and low intensity manipulations. By contrast, for example, chronic disease is, by definition, of long duration and often highly stressful, and often occurs in older individuals with a different set of life experiences and backgrounds. For those interested in changing health behavior, behavior change is a long-term process, often with recurrent relapses. The differences between laboratory research and prevention, treatment, and/or rehabilitation in the real world are self-evident and too numerous to mention here.

To this point, our comments may only appear to have implications for external validity, but inferences about relationships found for variables at different levels of analysis may be affected. For example, suppose a researcher wants to study the responses of college students to a stressor, such as exposure to an emotionally arousing situation. The students’ higher-than-average SES, cognitive aptitudes, better physical health, and so forth, represent a restricted range on a variety of psychological, biological, or structural dimensions. Furthermore, the subjects are typically tested in an artificial environmental with a short-term stressor. Just as correlations between two variables are attenuated when the range of either one or both of the variables is restricted, so the movement of processes at different levels of analysis will be restricted. The failure to observe unidirectional or bidirectional change across variables (at the same or different level of analysis) may merely be a function of restricted ranges of the stimuli/or and responses. Further, as noted above, the direction (i.e., sign) of effects or associations often differ between college students and older subjects, lab, and field (Peterson, 2001; Mitchell, 2012). Indeterminacy about the nature of the relationship across different types of outcomes (e.g., physiological and psychological) has the potential to undermine theoretical clarity and prediction across variables within and between levels.

How can the generalizability of social psychological and other behavioral research to health psychology be improved? A radical solution would be revise research norms to require researchers to initially test their hypothesis on a diverse population sample. If a significant effect is not captured in a heterogeneous sample, this suggests the effect probably is weak or nonexistent. Conversely, if the hypothesis is confirmed, this provides confidence about the robustness of the effect and potential for future research.

All social-personality or health psychological research need not to be conducted in more representative samples and settings, but selective replication is called for when there is reason to believe that the findings might be biased by a peculiar database or setting. For those researchers who endeavor to apply personality-social psychological theory and results to health-related problems, however, more effort devoted to replication and representativeness is recommended.

A likely response is that broader sampling is expensive and time-consuming, however, as noted earlier, samples were more heterogeneous in earlier decades when there were actually fewer resources available to researchers (the work of Kurt Lewin in the late 1940s is a conspicuous example). This practice of using college students was extensively adopted precisely because it is convenient and of low cost. However, there are developments that could put an end to the extensive use of subject pools, and the age of convenience sampling may fade. These include the emphasis of funding agencies, such as NIH and the National Science Foundation, on broader public health significance of research in order to justify extramural funding, possibilities that institutional review boards may determine that the use of undergraduate required research exposure and subject pools is not permitted, and even changing beliefs in the scientific community regarding the value of this research. Moreover, the lay public, policymakers, and scientists from other disciplines often disapprove and perhaps even distain this approach of research using college subject pools. The extensive use of convenience samples also hampers the building of bridges between psychology and different disciplines, such as public health, where population representativeness and generality of findings are considered to be of primary importance. We believe that advancement of the field of personality and social psychology and health depends on conducting more research outside the laboratory on populations who are representative and relevant to the problem being studied.

Conclusion

In sum, personality and social psychology has much to contribute to health psychology, and the articles in this issue demonstrate these potential links. We believe that these contributions would be enhanced by broadening multidisciplinary links and expanding multidisciplinary training in the field, focusing on research outside the laboratory using representative samples, and addressing more clinically relevant outcomes. Moving the field further in these directions would not only increase its contribution to enhancing health and preventing disease but also greatly further personality and social psychological theory.

Acknowledgments

Jerry Suls, Department of Psychology, University of Iowa; David S. Krantz, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences; Geoffrey C. Williams, Healthy Living Center, Center for Community Health, University of Rochester.

This commentary partly was supported by grants from the National Center for Research Resources (M01-RR00044) awarded to the University of Rochester General Clinical Research Center, and the National Center for Research Resources ARRA Supplement (UL1RR024160) awarded to the University of Rochester’s Clinical and Translational Science Institute.

The opinions and assertions herein are those of the authors and do not necessarily represent those of the Uniformed Services University or the Department of Defense.

Footnotes

1

There is some irony here. Festinger was a strong proponent of experimental methods, but he was also the senior investigator of two nonexperimental social psychology classics: a survey study of ex-GIs and their families residing in married dorms at the Massachusetts Institute of Technology (Festinger, Schachter, & Back, 1950) and a case study of cult followers in a Midwestern community (Festinger, Riecken, & Schachter, 1956).

Contributor Information

Jerry Suls, University of Iowa.

David S. Krantz, Uniformed Services University of the Health Sciences

Geoffrey C. Williams, University of Rochester

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