discussion #5 disease

George Engel’s contribution to clinical

Graeme C. Smith, James J. Strain

The work of George Engel permeates the practice of
medicine in the Western world to an extraordinary
degree. Engel’s thesis was that a physician’s need to
know and understand must be complemented by an
ability to make the patient feel known and understood.
That thesis has come to be regarded as common sense,
and that which is expected of a doctor. It has helped
medicine to remain human in the face of enormous
pressures to remain biological. Engel’s exposition of
the biopsychosocial model [1] epitomized his drive to
have all doctors, not just psychiatrists, attend to the
patient’s culture, psychological being, behaviour and,
most importantly, the patient’s inner life in a systematic
manner. It reflected his years of teaching medical stu-
dents and residents in all disciplines. It reflected his
unique qualifications as an internal medicine physician
and a psychoanalyst. It reflected his intense case studies,
the most famous of which was that of Monica, an infant
with a gastric fistula whom he followed for 40 years,
observing the links between her affective states and
gastric functioning, and her relationships. It reflected his
personal commitment to the entire context of the patient
including the emotional needs and development of all
with whom he worked.

Many leaders in the field of psychiatry in Australia,
including a number who were subsequently appointed to
chairs (e.g. Wallace Ironside and Bruce Singh), worked
with and were trained by Engel in Rochester, New York.
A number of Australian non-psychiatric physicians
were similarly trained. Psychoanalysis was well enough

developed in Australia for these professionals to find a
fertile field for the application of Engel’s ideas. Medi-
cine in Australia became biopsychosocial without
knowing it, in the way that the Western world became
psychoanalytic without knowing it in the 20th century. A
generation of Australian medical students and psychiatry
trainees have been taught to interview in a way that
establishes a context for symptoms and illness, and
allows them to produce a full and meaningful narrative
answer to the question, ‘why is this patient ill in this way
and presenting at this time?’.

This paper focuses on Engel’s influence on clinical
psychiatry, through the development of the concepts of
conservation–withdrawal and the biopsychosocial model
and their application in teaching, training and clinical
work at the interface of psychiatry and medicine. It also
examines the intellectual context of these concepts,
and their legacy. We conclude that we are indebted to
George Engel for a more comprehensive understanding
of how medicine – medicine and psychiatry – should be
practiced, for epitomizing the good doctor.


Engel’s work as a conceptual psychoanalyst and keen
clinical observer led first to the seminal proposition of
the concept of conservation–withdrawal which he devel-
oped with Schmale and colleagues [2]. This was a refor-
mulation of their earlier concepts of the ‘giving-up’
reaction and its component ‘helplessness’ and ‘hopeless-
ness’ dimensions, as elucidated by Sweeney

et al

. [3].
Engel and Schmale proposed that the affective response
of giving-up, when it follows real, threatened or sym-
bolic loss of a highly valued form of gratification or
object, tends to precede the onset or exacerbation of
somatic as well as psychic disease. They proposed that
it facilitates the manifestation of whatever disease
potential or predisposition exists in the individual or
environment to become. ‘Giving up’ includes a loss

Graeme C. Smith, Professor (Correspondence)

Department of Psychological Medicine, Monash University, Monash
Medical Centre, 246 Clayton Road, Clayton 3168, Victoria, Australia.
Email: [email protected]

James J. Strain, Professor

Mount Sinai/NYU Medical Center, Division of Behavioral Medicine and
Consultation Psychiatry, New York University, New York, USA

Received 5 February 2002; revised 22 March 2002; accepted 25 March

Australian and New Zealand Journal of Psychiatry 2002; 36:458–466


of self-esteem, a disruption in object relationships, a
decrease in motivation, and an expectation that such
a state may be enduring. Helplessness was defined as a
feeling of being left out or abandoned where loss of
gratification is perceived as caused by external events or
objects. With hopelessness, the individual feels that he
or she alone is responsible for the loss and that there is
nothing that he or she or anyone else can do to over-
come it. Engel and Schmale proposed that conservation–
withdrawal is ‘the basic biological anlage serving sur-
vival’ that comes to be reflected in the behaviour and
psychological experience of the human being. Giving up
is defined as the ‘inner experience of the person in whom
the conservation–withdrawal mechanism has been acti-
vated’ [4]. They argued that organisms are confronted,
periodically or by chance, with unfavourable environ-
mental conditions, in which a withdrawal rather than an
active response is highly adaptive and serves ‘an ele-
mental survival function’. Appraisal of the situation
indicates ‘either a too intense input which cannot be
assimilated (as overload)’ or ‘a deficient input which
indicates an unavailability of supplies (underload)’. In
such cases, activity is not only fruitless but is a waste
of scarce resources.

Seligman’s complementary learned helplessness
model of depression, developed contemporaneously on
the basis of animal studies, took these ideas further, in
that it led to an effective form of treatment for depres-
sion; cognitive–behavioural therapy. As proposed origi-
nally, learned helplessness produces a cognitive set in
which people believe that success and failure is inde-
pendent of their own skilled actions [5]. Abramson

et al

[6] offered a cognitively orientated reformulation of the
learned helplessness model of depression that can be
seen to have been influenced by Engel and Schmale’s
work. Abramson

et al

. argued that people have a charac-
teristic explanatory style, which they tend to apply to
events despite the context. Those who have a pessimistic
explanatory style were proposed as being especially vul-
nerable to depression when faced with uncontrollable
life stressors. Cognitive–behavioural therapy used hypo-
theses such as these to develop effective psychotherapy
techniques for depression.

There has been renewed interest in the ‘giving-up’
concept. Further work has helped to clarify the distinc-
tion between depression and demoralization, and this has
become an important issue in the field of physical/
psychiatric comorbidity [7]. To a limited extent, Engel
and Schmale’s claims that ‘the giving-up process was
found as an antecedent to disease of all categories’
[4, p.23] has received empirical support. Depression has
been shown to be a risk factor for increased morbidity
and mortality [8,9].

The concept of conservation–withdrawal is paradig-
matic of the way in which the relationship between
psychosocial events and physical status can be addressed
within a wider biopsychosocial model; this was Engel’s
next major contribution.

The biopsychosocial model

Engel’s biopsychosocial model is his best-known
contribution. It stands as one of the most influential ideas
in Medicine in the 20th Century. Engel’s claim for the
scientific status of the model may draw criticism, but in
that it articulates historical clinical wisdom and has
stimulated a plethora of conceptual developments, it has
become a key motto of medical education and practice.

The model and its claims for being scientific

In his paper ‘The clinical application of the biopsycho-
social model’ [10], Engel argued that physicians
approach patients and the problems that they present in a
way that is very much influenced by the conceptual
models in relationship to which their knowledge and
experience are organized. He knew that physicians are
largely unaware of the power such models exert on their
thinking and behaviour. He thought that this was because
the dominant models are not necessarily made explicit.
Rather they are part of the fabric of education and
cultural background which is taken for granted. He
described the prevailing model at the time as being
‘biomedical’. He offered his alternative model, the

biopsychosocial model

. He argued for it on the basis of
good medical practice:

‘The biopsychosocial model does not add anything to
what is not already involved in patient care. Rather it
provides a conceptual framework and a way of thinking
that enables the physician to act rationally in areas
excluded from a rational approach . . . . The reduction-
ism and mind-body dualism on which (the biomedical)
model is predicated requires that (data) must first be
reduced to physico-chemical terms before they can have
meaning’ [10].

He claimed that the model was based on a systems
approach, and constituted a scientific model constructed
to take into account the missing dimensions of the bio-
medical model, which does not include the patient and
his or her attributes as a person.

Engel claimed that the biopsychosocial model would
enable the physician to extend application of the scien-
tific method to aspects of everyday practice and patient
care not previously deemed accessible to a scientific
approach or even deemed worthy of examination, for


example, inner feelings. Engel makes the point in his
1977 paper [1] ‘. . . most recognize how ephemeral and
insubstantial are appeals to humanism and compassion
when not based on rational principles’. Engel’s argu-
ment for the biopsychosocial model being a scientific
one rested on his observation that the doctor’s task is to
find out how and what the patient is or has been feeling
and experiencing, to formulate an explanation, and to
engage the patient’s participation in further clinical and
laboratory studies to test such hypotheses. The sole reli-
ance on biophysical or somatic data was claimed to be
insufficient and would lead to erroneous conclusions.
He contrasted the biopsychosocial model with what he
described as counter dogmas; those of ‘holistic’ and
‘humanistic’ medicine. He stated that these qualify as
dogmas to the extent that they eschew the scientific
method and lean instead on faith and belief systems
handed down from remote and obscure or charismatic
authority figures.

Engel skilfully argued that whether the illness be
diabetes mellitus or schizophrenia, it was necessary to
include four dimensions: (i) physical, (ii) psychological
(including inner feelings), (iii) social, and (iv) behav-
ioural. He claimed that without an examination of all
four, sufficient understanding and clinical practice
would be truncated and incomplete, and possibly lead to
inadequate diagnosis(es) and/or treatment(s). Further-
more, he said, all four dimensions could and should be
examined scientifically with the patient as partner. In
that sufficient interview skills were necessary on the part
of the physician to obtain a comprehensive database in
all four dimensions, this proposal had major implications
for training in both psychiatric and non-psychiatric
medical disciplines.

The biopsychosocial model requires training in a
particular type of medical interview. The technique was
described in ‘Interviewing the Patient’ which Engel
wrote with William Morgan [11]. Engel articulates how
the interview is guided by the clinician’s conceptual
frame of reference – the biomedical or the biopsycho-
social. The information queried and obtained will be
affected by this orientation. ‘Hence,




(inner viewing), and


(interviewing) are the basic methodologic triad for clini-
cal study and for rendering patient data scientific’ [12].
In 1997 Engel once again emphasized the importance of
the medical interview not only as a human encounter but
also as a rigorous instrument to better understand the
patient and help explain the data that the patient presents

We can see that such a theoretical model allowed a
reunification of biological models of psychiatric illness
and psychosocial models – ‘biological treatments and

talking treatments.’ The biopsychosocial model argues
for a combination of both. It also argues that a taxonomy
built on observable behaviours, such as DSM-IV, even
though it has five axes, is really a static triaxial diagnos-
tic schema rather than a biopsychosocial formulation.
There is no obligation to discern or integrate the inter-
relationship of psychological state and trait disturbances
(axis I and II) with biological dysfunction (axis III) or
stress and social functioning (axis IV and V). In DSM-
IV these are regarded for the most part as separate
domains, which is reminiscent of the non-integrated
triaxial taxonomy developed by the World Health
Organization in the 1970s. The integration of biology,
psychology, social issues and behaviour, and the inter-
action among them, is the hallmark of the biopsychosocial
model of disease promulgated by Engel. As such, this
model moves psychiatry back into being a medical dis-
cipline, while at the same time expanding the dimensions
and comprehensiveness of other medical disciplines.
The biomedical model is too narrow a basis for medical
practice. Learned helplessness, illness behaviour, failure
to cope, hypochondriasis, somatoform disorders, psy-
chological factors affecting physical illness, somatiza-
tion and non-compliance are all examples of problems
that confront the practitioner of medicine and Engel’s
model allows them to be researched, taught, and incor-
porated into clinical practice.

The intellectual context of Engel’s biopsychosocial

The psychosomatic medicine movement of the mid-
twentieth century espoused many of these notions inher-
ent in the biopsychosocial model, but failed to enunciate
them in a convincing way [13,14].


It took seriously the
concept that what is uniquely human is the capacity to
assess one’s mental state. It readily embraced psycho-
analysis as a tool. That alienated psychiatry from the rest
of medicine and from biological psychiatry, both of
which became caught in rationalism. In embracing
psychoanalysis as its tool, psychosomatic medicine
employed explanatory concepts of folk narrative; con-
cepts like love, hatred, fear, belief, feelings of weakness
and dependence, etc. [15]. But it failed to sufficiently
examine another Engel contribution – the ‘


’. [16]. This formulation stated that just as
psychosocial issues may affect the body, for example,
stress and an acute asthmatic attack, bodily processes
(somatic processes) can and do affect the mind, for
example, delirium from a fever or metabolic imbal-
ance. Much of the psychosomatic effort was directed to
the mind to body axis, ignoring the fact that medical
illness can have untold effects on the central nervous


system and the mind, as exemplified in HIV patients.

somatopsychic phenomenon

is important in all of
psychiatry, and especially so for the consultation–liaison

Lipowsky, a major North American psychiatrist, also
conceptualized the relationship between biological,
psychological and social factors, but did so within the
psychosomatic medicine paradigm, which he defined as
comprising an approach, a science, and a set of tech-
niques [17]. Psychosomatic medicine as an approach
was said to have as its hallmark the insistence that
psychosocial as well as biological factors be considered
in the diagnosis, treatment and prevention of all diseases.
Psychosomatic medicine as a science was said to study
the relationship between psychological and biological
phenomena as they occur in, and are influenced by,
the social and physical environment, in both health and
disease. Psychosomatic medicine as a technique was
said to involve the clinical application and teaching of
the psychosomatic approach, with a particular emphasis
on the art of consultation. Psychosomaticists were the
advocates of the biopsychosocial approach, they aimed
at studying the field scientifically, and they needed skills
in communication. Lipowsky made no claims for the
scientific properties of the biopsychosocial model, but
was very influential in providing consultation–liaison
psychiatry with a conceptual framework. He moved
beyond traditional consultation to the idea of the care-
taking team: the consultation–liaison psychiatrist was a
key member of the team that taught and practised
psychological medicine of the medically ill. Lipowsky
was an important force urging psychiatry to consider the
body as well as the mind, particularly in the medically
ill. He assisted the move of the biopsychosocial model to
psychiatry, in particular, consultation–liaison psychiatry.

Balint, a Hungarian psychoanalyst who had migrated
to England, explored similar issues with groups of
general practitioners in London, but did not use the term
biopsychosocial. However, like Engel, he believed that it
was important to study these complex issues in a system-
atic way. His book, ‘The doctor, his patient and the
illness’ [18], first published in 1957, summarizes his
systematic studies using action research. It led to the
identification of important concepts, such as that of the
‘basic fault’ and the ‘deeper diagnosis’, which have
become pivotal in working with doctors in understand-
ing what they do. Other important concepts to emerge
were those of the ‘apostolic function of the doctor’ and
the ‘doctor as drug’. It gave us a model of investigation,
‘the Balint Group’, which has been used widely ever
since. By facilitating the group’s exploration of their free
associations and feelings about the material presented,
Balint was able to allow these general practitioners to

see that their preoccupation with physical diagnosis and
authoritative prescription was often a defensive reaction
and did not meet the needs of their patients. One might
think that it would not be necessary to demonstrate this
40 years later, but those who work with general prac-
titioners in Balint groups report that little has changed. It
seems that although modern medical education empha-
sizes the biopsychosocial approach, it requires some-
thing other than the didactic approach to allow doctors to
understand the nature of the doctor-patient relationship.
It is as if doctors require ongoing psychotherapy, that is,
ongoing working through of issues that have to do with
unconscious processes.

Balint’s book [18] also discusses the concept of illness
behaviour which was later elaborated by Mechanic,
Pilowsky and others in a development of Parson’s
concept of the ‘sick role’ [19,20]. It is there in Engel’s
‘The clinical application of the biopsychosocial model’
[10], where he expands on the concept that the patient’s
tasks and responsibilities complement those of the phy-
sician. The concept of illness behaviour, like that of
the biopsychosocial model, has had a great influence on
Western medicine. What a patient makes of his or her
symptoms is what determines what they do about them,
and about any advice given to them. Doctors learn this
through bitter experience. In the introduction to the
millennium edition of Balint’s book [18], Michael
Balint’s son John, Professor of Medicine and Director of
the Center for Medical Ethics at Albany Medical College
New York, argues that the rise in patient autonomy and
the controls imposed on doctors by a market-driven
philosophy have altered the doctor-patient relationship
in a way that can be traumatic for both. As doctors are
forced into partnerships with patients, there is an even
greater need for them to understand the forces that work
in shaping that relationship.

Teaching the model

In a major pedagogic contribution: ‘The biopsycho-
social model and medical education: who are to be the
teachers?’ [21], Engel examines the issue of who would
be the optimal teachers for this model, and what was the
place of psychiatry in it. It is important to note that he as
an internist and trained psychoanalyst had directed the
Medical Psychiatry Liaison Fellowship at the University
of Rochester School of Medicine for 33 years and men-
tored more than 150 fellows from diverse medical dis-
ciplines. Engel believed that role models and teachers
should come from within the discipline currently studied
by the students, residents or fellows, (e.g. internal medi-
cine, primary care, obstetrics-gynaecology). He believed
that psychiatrists could be the primary messenger to a


cohort of such medical teachers (the secondary messen-
gers) who would be the direct teachers to the practitioners –
the tertiary messengers. ‘. . . I like to refer to these
“mutants” as the cyclic AMP – the “second messengers”
of the educational process’. He felt that the gap was too
great for psychiatrists to be the direct teachers of future
medical practitioners in individual disciplines. He envis-
aged the Engel Fellows to be the second messengers –
the ‘mutants’, and the pedagogic model for promoting
the biopsychosocial model throughout all medicine. It is
important to note that in a study to develop a taxonomy
of mental health training programmes for primary care
physicians reported by Strain

et al

. [22–24], after a site
visit for the National Institutes of Mental Health to
Rochester, New York, the teachers in the Engel fellow-
ship programme made it clear that Engel fellows – the
second messengers – would not perform complicated
psychiatric treatments for complicated psychiatric ill-
nesses, but would rather refer the clinical care of such
patients to psychiatrists.

In addition, Engel believed that such ‘mutants’ would
have an impact on psychiatrists as well, promoting the
biopsychosocial model for psychiatric consultations,
patient evaluation, and treatment strategies. The impor-
tant message for psychiatry here was to find and help
develop key individuals within medical specialties as a
peer group conversant with the psychological, psychi-
atric, social and behavioural aspects of patient behav-
iour; that teaching them would be the most optimal
approach to facilitate learning with non-psychiatric
medical specialties.

The Balint–group members could be secondary or
tertiary messengers in the Engel model. However,
Balint, a psychiatrist, was teaching primary care physi-
cians, most likely practitioners and perhaps some teach-
ers. Balint has shown that with this group of self selected
primary care physicians the distance between psychi-
atrist and internist is not too great to have knowledge and
role modelling bridge the gap. Similarly, Lipowsky has
the psychiatrist as teacher in his consultation–liaison

Strain (a psychiatrist) and Hamerman (Chairman of the
Department of Medicine, Montefiore Hospital, Albert
Einstein College of Medicine) developed a programme
where an internist and a psychiatrist would co-teach on a
medical ward during ongoing medical rounds [25,26].
The internists were especially hand picked from the
Department of Medicine and especially trained to iden-
tify biological, psychological and social issues that were
seminal for patient care. Both the psychiatrist and
internist would interview the patient and present their
formulation of the patient in front of the medical
students, interns and residents. These rounds were held

weekly on all the medical units and the internal medicine
physician attending became known as the


(a Scandinavian word implying ‘wise man of the vil-
lage’). Similar rounds were established at the Mount
Sinai Hospital, New York, with the Chairman of Medi-
cine and the Director of the Consultation–Liaison
Psychiatric Service as co-teachers performing weekly
biopsychosocial teaching rounds on the medical wards.
They also occurred on the otolaryngology service with
the Chief of the Service serving as ombudsman. These
teaching models were conceived to enhance the chance
of the teaching to be seen as relevant by the students on
the medical service, since an important attending con-
sultant from their discipline (medicine, otolaryngology)
was a co-teacher. It was conceived that the teaching
inoculum had a better chance of taking when a teacher
of the same discipline dispensed the biopsychosocial

One of the criticisms raised is that Engel offered no
evidence of the efficacy of such teaching. Goldberg and
other British colleagues [27] have made a systematic
study of how general practitioners interview patients
with unexplained medical symptoms. They have shown
that it is possible to change the physician’s interview
behaviour and for them to institute therapies that permit
patients to reattribute their somatic symptoms and relate
them to psychosocial issues. The underlying principles
are similar to those enunciated by Engel in his bio-
psychosocial model.

In his classic text, ‘Psychological Development in
Health and Disease’ and in other papers, Engel argued
for the use of patients from services other than psychi-
atry in teaching psychological medicine to junior medical
students [16,21]. That has characterized undergraduate
medical teaching in Australia, and has become even
more pertinent as psychiatric services withdraw into
becoming services for psychosis only. Another impor-
tant point made by Engel was that we must respect the
range of personal experience of medical students.

Pain as an example of the application of the model

Engel made a major contribution to our understanding
of the concept of psychogenic pain in an early and
seminal paper which illustrates how long the incubation
period of the model was [28]. By application of his
contextual interviewing technique, he obtained a dense
narrative which allowed him to identify a number of
recurring patterns in the childhood of patients presenting
with chronic pain that had not responded to conventional
treatments. These included a history of physical or
verbal abuse, a history of differential patterns of punish-
ment by parents, a history of being rewarded for illness


or pain, a history of guilt for perceived responsibility for
pain in others, and a history of deflecting the aggression
of parent towards others onto the self. Even as late as
1987, when the DSM-III-R was promulgated, the cat-
egory of pain in psychiatry’s taxonomy was limited only
to the psychological dimension – conversion pain. There
was no bio or social part of the formulation. With DSM-
IV pain was reformulated to include pain from a pure
biological source, combined psychological and bio-
logical aetiologies, or unknown sources. This is an example
of expanding psychiatry’s nomenclature toward a bio-
psychosocial template.

Consultation–liaison psychiatry as a service example
of the model

Consultation–liaison psychiatry had its origins at the
time when Engel was developing his ideas. It was his
energy in reminding doctors of their responsibilities


the biomedical model that helped consultation–
liaison psychiatry establish itself as the specialty most
able to help physicians employ the biopsychosocial
model in their practice [29]. Engel referred to the debt
that he paid to his colleagues in the medical–psychiatric
liaison group at the University of Rochester. Engel’s
original debt is to John Romano, a psychiatrist who
taught Medicine at the Peter Bent Brigham, Harvard
Hospital in Boston. This influence continued when
Romano took Engel to the medical school at the Univer-
sity of Cincinnati. Engel continued his psychological
learning in psychoanalysis in Chicago. George Engel
thus had had outstanding training when he assumed his
post at the University of Rochester.

It is our belief that consultation–liaison psychiatrists
are the second messengers as teachers in psychiatry – the
‘mutants’ in Engel’s language [21]. They are not like
ordinary psychiatrists in that they are both conversant
and comfortable with medical illness, medical drugs,
medical settings, and talking with non-psychiatric physi-
cians and medical care teams. Perhaps as few as 5–10%
of psychiatrists are really comfortable working/teaching/
treating in the acute care medical setting, particularly
high tech. settings such as CCUs, ICUs and transplant
psychiatry. It appears that consultation–liaison psychi-
atry came to this concept of the need for a hybrid teacher
especially as it moved from the consultation setting to
the liaison setting where the psychiatrist joined the team
as a co-teacher and …

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