Psychoanalysis and Psychotherapy

Free Associations

The Growth of George Engel's Biopsychosocial Model

         Corner Society Presentation – May 24, 2000

                          By Theodore M. Brown

I’ve set myself a very difficult task. Not only is George Engel’s “biopsychosocial model” a large and challenging subject, but because it has been a central, indeed, defining feature of our medical school curriculum for more than fifty years, many of you in the audience are intimately familiar with it in teaching and practice settings.

     What could I possibly add? I’ve only been in Rochester for the past 23 years, and although I got to know Dr. Engel pretty well – even “rounding” with him in the early eighties and interviewing him on tape while sipping tea at his home in the later eighties – I am an historian, not a physician, and most of my knowledge comes from oral testimony and the written record, published and unpublished.

      What I think I can add – and this is what historians do much of the time – is depth and perspective. I have tried to take what I have learned from Dr. Engel and his writings and placed it against a background of his entire, evolving career and of what else was happening in American medicine during the seven decades when he was active in it.

     Some of the story is, of course, familiar to you. Many of you doubtlessly heard from Dr. Engel – as I did – on numerous occasions about certain key moments: how George started out under the long shadow of his famous uncle Dr. Emanuel Libman (the L in George L. Engel) to become a very biomedically-oriented investigator; how Dr. Soma Weiss of Harvard in the early forties cajoled George into reluctant collaboration with the brilliant young psychiatrist John Romano; about the investigative work Romano and Engel began together at Harvard and explored more fully at Cincinatti a few years later; about the curricular innovations they experimented with at that medical school and then brought to ours in 1946 for much more extensive development; about the linked growth of Dr. Engel’s Medical-Psychiatric “Liaison” fellowship training program and the infusion of the Rochester medical curriculum with what for a long time were called “psychosomatic” concepts and clinical examples; about the “Monica” studies beginning in the fifties and their continuation and elaboration over many decades; about the group that coalesced in the fifties and continued actively in the sixties with the contributions of Franz Reichsman, Bill Greene, Art Schmale and Sandy Meyerowitz who, with Dr. Engel, made Rochester famous for studies on “conservation-withdrawal,” “giving up-given up,” and the “helplessness/hopelessness” affect (“He-Ho”) as a “final common pathway” to the onset or exacerbation of a wide variety of diseases; about the articulation of the “biopsychosocial model” in the seventies and its achievement of world-wide recognition in the eighties; about the development of the Program in Biopsychosocial Studies under the leadership of Tim Quill, Tony Suchman and Rich Frankel in the nineties and the role it has played, with Dr. Engel’s encouragement and Dean Hundert’s support, in the new “Double Helix” curriculum.

     Much of this, I suspect, is familiar to most of you in the room, so what I would like to do is take a few of these familiar moments and explore them more fully. I hope to provide context and perspective as I have already indicated, and in some cases I can provide depth derived from interviews, archival digging, and focused reading in published sources.

     Let me start with uncle Emanuel, a truly formidable figure.

                        Slide 1 – Libman on Time magazine cover

Libman was a world-famous medical scientist and clinician affiliated for most of his career with Mount Sinai Hospital in New York City and renowned for several widely heralded discoveries. He was best known for his pioneering work on the blood-culturing of bacteria and for identifying the condition of subacute bacterial endocarditis, an insidious and complex infection of the membrane lining the cavities of the heart.

     George grew up in Libman’s household in terror that he might one day embarrass “Uncle Manny,” so he set out on the straight and narrow path of biomedical science. He majored in chemistry at Dartmouth College, which he entered at age sixteen in 1930. He was strongly committed to the ideas of Jacques Loeb, the famous “apostle of mechanistic conceptions in biology.” He obtained permission from the Dartmouth biology to set up a small laboratory in which he worked with amoebae and paramecia, trying to duplicate Loeb’s experiments on mechanistically-produced “tropisms.” In the same materialist and “anti-mystical” spirit, George wrote his first college paper as an assault on intuitive and introspective psychology, “Thought as a Product of Brain Metabolism.” In the summer between his junior and senior year, he obtained what in those days was a very rare position for a college undergraduate, a research post at the Woods Hole Marine Biological Laboratory, where he worked closely with Ralph Gerard, professor of physiology at the University of Chicago and one of the pioneers of neurochemistry. George’s first major project, which led to his first publication (in 1935, at age 21!), was a study of the distribution of organic phosphorus compounds in the muscles of marine invertebrates.

     After Dartmouth, George attended the Johns Hopkins Medical School. It was the obvious place to go for an aspiring biomedical scientist. During his pre-clinical years, George was, in fact, a scientific celebrity. As a result of his continuing association with Ralph Gerard, he was asked by the Rockefeller Foundation to spend two months during the summer of 1935 at the Leningrad Institute of Experimental Medicine in the laboratory of Alexander Gurwitsch, a Russian physiologist working on “mitogenetic radiation” and a colleague of Ivan Pavlov. Since, by coincidence, the XV International Physiological Congress took place that summer in Moscow and Leningrad, Congress participants – including several Hopkins physiology instructors – were treated to tours of Institute labs by George serving as tour-guide and translator (his Russian was very good).

                        Slide 2 – Engel photo of Pavlov

His Hopkins reputation thus assured, George was also acknowledged in his clinical years for his ferociously Libman-like diagnostic prowess. Moreover, uncle Manny arranged for him to work during the summer of 1937 at Boston City Hospital where he met Soma Weiss, soon to become Harvard’s Hersey Professor of the Theory and Practice of Physic and physician-in-chief of the Peter Bent Brigham Hospital.

     After medical school graduation in 1938, George began his postgraduate training at Mount Sinai Hospital in New York City. Mount Sinai was an intense, high-energy place that modelled itself to a large extent on the Johns Hopkins Hospital and was still very much in the Libman mode. Indeed, uncle Manny was a “consulting physician” until his death in 1946 and in the late thirties still published occasionally in the scientifically prestigious Journal of the Mount Sinai Hospital. The chief of medicine during Engel’s house officership, Dr. Eli Moschowitz, moved, however, in certain new, dramatically different directions. Moschowitz was, in fact, part of the “psychosomatic” wave that was sweeping through American medicine at that time.

                        Slide 3 – title page of Dunbar’s “Emotions and Bodily Changes” (1935)

                        Slide 4 – Cannon on “Role of Emotion” in 1936 Annals of Int. Med.

                        Slide 5 – title page of Psychosomatic Medicine (1939)

Moschowitz was interested in the role of emotions in essential hypertension, Graves Disease, and ulecerative colitis and was open to the ideas of psychoanalysis. In fact, while George worked on his medical service, psychoanalytically-based psychiatrists rapidly expanded their presence in the outpatient department and on the floors of the hospital. In 1939, in a major reorganizational move, the well-known psychoanalyst Lawrence Kubie moved from Columbia to Mount Sinai as Asssociate Psychiatrist and as head of a new “psychosomatic” service. Kubie described the move a few years later as part of the “invasion of a general hospital by ... [a] large group of psychiatrists” and as an effort to create “a profound and rapid change in the practice of medicine itself.”

     George, however, remained skeptical and aloof. He dismissed most of what psychoanalytic psychiatrists had to say as “laughable” and as “hogwash” and continued to focus on physiological and biochemical investigations. He worked, for example, on “the signficance of the carotid sinus reflex in biliary tract disease” and on “‘epinephrine shock’ as a manifestation of a pheochromocytoma of the adrenal medulla.” When George did collaborate with a young Mt. Sinai psychiatrist, Sydney Margolin, he continued to maintain a reductionist point of view, trying to link neuropsychiatric symptoms to the precise tracings of the electroencephalograph and insisting on explaining them as the mere consequence of “altered physiologic or biochemical reactions.” Perhaps modelling his approach on Soma Weiss’ vitamin therapy in cardiovascular disorders, he attempted to correct neuropsychiatric symptoms in organic disease with vitamins and other metablolic adjustments. And by 1941, George eagerly prepared to leave Mount Sinai and its psychosomaticists behind, so that he could return to Boston and work again with Soma Weiss.

     George apparently did not realize that Weiss had shifted his focus in some subtle but important ways. Although he still actively pursued the studies in pathophysiology, pharmacology and pharmacotherapy that had brought him fame and universal admiration, Weiss had also moved with the times and become interested in the emotional dimensions of clinical medicine. In 1940 he published in the Journal of the American Medical Association an Alpha Omega Alpha address on “The Medical Student Before and After Graduation” in which he pointedly told his student audience that “social and psychic factors play a role in every disease, but in many conditions they represent dominant influences” and that “mental factors represent as active a force in the treatment of patients as chemical and physical agents.”

     When George arrived at the Brigham in 1941 he was shocked to discover that Weiss had introduced some dramatic changes since the summer of 1937. He had invited a young psychiatrist, John Romano, to join the Department of Medicine and help teach the emotional and psychological dimensions of patient care. Fully integrated into Weiss’ medical service, Romano conducted rounds at patients’ bedsides, where he would pull up a chair and listen at length to their stories just as he would on a psychiatric ward. George watched as Romano, with Weiss’ blessing, placed the patient’s narrative of his life and illness experience in a central position in clinical evaluation. To add to Engel’s shock, Weiss also strongly encouraged him to work collaboratively with Romano on a research project focused on delusional patients. Engel would study them with precise electroencephalographic techniques while Romano would investigate their mental states in psychological detail, after which the two investigators would compare their independent observations. Even though Engel “condescended” to learn the mental status exam and approached Romano in a “patronizing” manner, the unlikely collaborators found, as Weiss very likely suspected they would, that the features of the EEG very closely correlated with the clinically determined mental states.

     George had another major shock in January, 1942, when Weiss died suddenly of an unsuspected intracranial aneurysm. Romano had already accepted a position as Professor and Chair of the Department of Psychiatry at the University of Cincinnati College of Medicine and promptly offered George the opportunity to join him in that department. George at first refused but was persuaded to move by Eugene Ferris, one of Weiss’ former fellows and collaborators who was now in the Department of Medicine at Cincinnati, where he also offered George a position. George thus came to Cincinnati in 1942 with appointments in both Medicine and Psychiatry and found in each of the departments an extraordinary group of individuals. Ferris and Arthur Mirsky were the standouts in Medicine, while Romano, Milton Rosenbaum, and Maurice Levine made Psychiatry equally stimulating. George found the Cincinnati group “the most exciting I’d ever encountered, before or since.”

     For George, the single most important event in Cincinnati was the abandonment of his resistance to psychological factors in medicine. At first, he tried to ignore the psychosomatic buzz in the Cincinnati air as he set out to trip up the psychiatrists by demonstrating somatic clinical findings they had missed. Gradually, however, he let down his guard. Ferris was instrumental as he took a broadly clinical approach to the wide-ranging studies of high altitude decompression sickness with which the Cincinnati group was deeply involved. Instead of sticking to physiological observations, Ferris led the group in watching a broad spectrum of clinical behavior, which left considerable room for psychological observations. In addition, Rosenbaum persuaded or perhaps manipulated George into doing psychotherapy with a patient who had complex reactions to pain. While supervising him in that psychotherapy experience over the course of a year, Rosenbaum helped Engel overcome his “stubborn resistance” to psychological matters and introduced him to the writings of Sigmund Freud.

     George served as an attending in the Department of Medicine and was responsible for a full range of medical patients, but he also undertook collaborative research in which he now explored in imaginative and open-ended ways the psychological as well as the medical dimensions of his clinical cases. With Romano, for example, Engel returned to one of his long-standing interests, syncope, only now with an important new psychological perspective. No longer keeping Romano and his psychological insights at a disdainful distance, Engel enthusiastically studied psychogenic fainting and distinguished between two basic types: vasodepressor syncope as an emotionally-precipitated, physiologically-based “vegetative neurosis,” and hysterical fainting in which loss of consciousness serves as a “substitutive or symbolic expression of emotion” unaccompanied by demonstrable changes in circulatory dynamics or EEG-measured brain metabolism. He had thus adopted exactly the distinction between two types of psychogenic disorder that the emigre psychoanalyst and psychosomatic leader Franz Alexander had recently made popular.

                        Slide 6 – Franz Alexander

Significantly, Engel and Romano presented their findings on fainting to the American Psychosomatic Society while Alexander sat in the audience and published them in the Society’s official journal, Psychosomatic Medicine, on whose editorial board Alexander served.

     In Cincinnati George developed important new interests in medical education. He participated in psychosomatic conferences in which a psychiatric resident was paired with a medical resident in case presentations attended by medical students and house staff. Under the inspiration of John Romano, he also conceived dramatically expanded and far more ambitious teaching possibilities. It was Romano’s strong conviction that “psychiatry should be taught in each year of the curriculum” and that “skilled psychiatrists should be assigned to teaching posts, not as occasional visitors but as intimate coworkers to the other teaching services of the hospital.” Engel and Romano called for a “more comprehensive frame of reference or conceptual scheme of disease [than that] with which the student had heretofore been ... familiar ... [a] conceptual scheme ... in which psychologic and social factors exist or coexist with more impersonal biologic factors, eventually to cause, provoke, or otherwise modify variations in the total human biologic behavior.” This was, obviously, an early statement of the “biopsychosocial model.”

     Before Romano and Engel got much further along, however, the Cincinnati chair of Medicine proved “somewhat resistant.” Romano soon afterwards decided to leave Cincinnati for Rochester, formally announcing his move in January, 1946. He had been given the opportunity to shape a brand new department of psychiatry, just then forming at Rochester. With the enthusiastic support of Rochester’s Chair of Medicine William S. McCann, Romano now had the chance to develop the training program that had been stymied in Cincinnati. He offered Engel an assistant professorship in the Department of Psychiatry with a specific invitation to play a major role in Rochester’s “psychosomatic” teaching, and McCann offered George an assistant professorship in Medicine. This time, Engel did not hesitate to join Romano.

     George’s first major assignment as Assistant Professor of Psychiatry and of Medicine at Rochester was to organize a “liaison program,” which meant establishing himself as an attending on the inpatient medical service, supervising fellows jointly appointed in Psychiatry and Medicine, conducting “ward walks and conferences on the medical divisions,” and introducing a once-a-week elective “Psychosomatic Clinic” for third- and fourth-year students and house officers. In 1947 Engel added a required course in “Psychopathology” for second-year medical students, in which he offered “consideration of the concepts of health and disease, with study of morbid psychologic experiences occurring at various life periods.” This course also introduced students to the clinical skills and theoretical principles involved in medical interviewing “as they relate to history taking and to psychotherapy.” In the early fifties arrangements were made for Engel and his expanding group of liaison fellows and junior faculty to conduct required weekly liaison conferences during the medical clerkship on each of the four inpatient floors. Unlike other liaison programs, an important feature of Rochester’s was its staffing largely by internists, which gave members of the liaison group credibility with their medical colleagues and allowed them to serve as effective role-models for the students.

     George also became a convert to psychoanalysis during his early years at Rochester. He began his personal analysis with Sandor Feldman in August, 1946 and used the experience to explore such long-resisted personal issues as the peculiarity of his family constellation dominated by Uncle Manny, the role of his mother (Manny’s sister) in the daily household drama as a “classic hysteric,” and the identity-shaping significance of being an identical twin.

                        Slide 7 – Engel family diagram

                        Slide 8 – Engel twins (George and Frank)

George then pursued a training analysis at Franz Alexander’s Chicago Institute for Psychoanalysis (he regularly commuted), where he learned the latest in psychoanalytic and psychosomatic theory, which he eagerly incorporated into his work. But George did not absorb Alexandrian approaches uncritically and remained an original and intellectually independent investigator. In 1953 he received a major research grant from the United States Public Health Service and another from the Foundations’ Fund for Research in Psychiatry. In 1954 he was elected president of the American Psychosomatic Society. The Liaison Group had grown large enough to allow the redistribution of many of his responsibilities and to free up more of his time for research. With a burst of energy, George undertook an ambitious new program of investigation, with three major and overlapping areas of study: ulcerative colitis, psychogenic pain, and depression and gastric secretion in a child with a gastric fistula, the famous “Monica” studies. Let’s focus on the latter.

     These began when George and Franz Reichsman were fortuitously presented with a naturalistic experiment on a infant, “Monica,” who was admitted to the Pediatric service of Strong in 1953. Monica had been born with a congenital atresia of the esophagus, which required that two fistulas be established, one in her neck to drain anything she took by mouth and one in her stomach through which she could be fed. Monica was discharged from the hospital ten days after her initial surgery and for a while did well at home. But when her home situation changed drastically, she failed to thrive, then dramatically declined, and was eventually readmitted to Strong at fifteen months in a dangerously marasmic and developmentally retarded condition. After she was nursed back to health and during a protracted hospitalization, Engel and Reichsman undertook a series of studies on Monica. They believed that they had near perfect study conditions to explore the connections between Monica’s behavioral responses, “object relationships,” and gastric secretory activity. Their access to Monica’s detailed case history and multiple opportunities for behavioral and physiological observation in the hospital let them probe and test various current psychoanalytic theories of psychobiological development and depression.

     Engel and Reichsman were especially struck by Monica’s characteristic reactions in the presence of new experimenters (“strangers”) in stark contrast to her reactions in the presence of her favorite, familiar one (Reichsman). In the first instance, Monica quickly lapsed into extreme motionlessness and inactivity, lying flat on the bed with flaccid muscles, ultimately passing into a state of “depression-withdrawal” and then sleep. In the latter instance, Monica quickly displayed unmistakable signs of pleasure. In each instance, her gastric activity was characteristically different and fully integrated with her total behavior. During the depression-withdrawal state and sleep, Monica’s hydrochloric acid production was markedly reduced and almost ceased entirely. During pleasure, it was just as markedly elevated, especially during reunion with her favorite experimenter.

                        Slide 9 – Monica composite

     Engel and Reichsman drew far-reaching conclusions from their experimental findings: “These data suggest that in this infant ... the processes whereby relationship with objects in the external world are established include a general intaking, assimilative organization in which the stomach participates as if the intention is also to take objects into it.” They also concluded that their findings lent strong support to current psychoanalytic theory: “From this it appears that the genesis of early object relations includes an assimilative process, largely orally organized. The processes concerned in establishing mental representations of objects and their libidinal and/or aggressive cathexes involve an essentially oral, intaking model.” Most generally, they saw in Monica’s behavior evidence that “two basis processes contribute to the development of a nuclear psychodynamic constellation which is potentially depressogenic. ... there is not only the active, oral, introjective anlage emphasized in classic theory, but also an inactive, pre-oral, pre-object anlage. ... Monica’s reaction of depression-withdrawal, including gastric hyposecretion ... [is] representative of the inactive, pre-oral phase, while the response to the return of the ‘good’ object, with its associated massive gastric secretion, provides the basis for a future introjective pattern.”

     In 1954 and 1955 Engel and Reichsman made several major presentations of their Monica findings and conclusions, which often included filmed highlights of their subject’s behavior. Their two most notable presentations were on successive days in May, 1955 to the American Psychosomatic Society and the American Psychoanalytic Association. At the latter meeting, their work was the focus of an all-day symposium, with panel discussions featuring several of America’s leading psychoanalysts. One stated that the study opened a new field of psychoanalytic research “through which visceral processes throw light on mental events which could not be understood otherwise.” Another noted that the Engel-Reichsman investigation “brings several aspects of psychoanalytic theory into sharper focus.” A third reported the symposium in the Journal of the Psychoanalytic Association, concluding that “surely this work of Engel and Reichsman (with the infant Monica) is and will remain a classic.”

     Generalizing from his Monica studies and other clinical investigations, Engel soon led his colleagues in the Liaison Group to a distinctive “Rochester style” of psychosomatic research. He first inspired William Greene, who in the early fifties had begun general, somewhat diffuse studies of “psychological factors” in patients with lymphomas and leukemias. In 1954-1955 he participated in a year-long “working conference” that had been organized and directed by Engel “to consider the dynamics of separation and depression.” After that experience, Greene summarized his principal conclusions in sharp and precise terms: “The occurrence of various types of losses, separations, or threats of separation in a period of 4 years prior to the apparent onset of lymphoma or leukemia is described. These included the loss of a significant person such as the mother, father, husband, or child by death or illness ... Half of such separations or losses during the 4-year prodromal period occurred during 1 year prior to the apparent onset. ... The majority of patients showed an affect of sadness or hopelessness for weeks or months prior to the apparent onset.

     Arthur Schmale also participated in Engel’s separation-depression conferences and became a major contributor for several very productive years. In 1955 he began “a survey of the psychobiological problems on a medical floor” which he completed two years later, demonstrating “a high incidence of separation and depression preceding illness.” He reported that “31 of the 42 patients experienced the onset of disease within a week after the final significant change in relationship” and that “24 patients and/or family members ... reported feelings of helplessness as the last predominant affect prior to the onset of the disease and another 10 patients who had given up completely ... reported feelings of hopelessness.” Schmale cautiously but provocatively concluded as follows: “The relatively short period of time between the final feelings of helplessness and hopelessness and the onset of the medical disease ... suggests that there are changes in biological activities related to these psychic reactions to unresolved loss. ... The exact influence of such psychic giving-up on resistance, immunity, organ dysfunction, and cell growth and multiplication awaits further study.”

     Building on this increasingly sophisticated and suggestive work of the fifties, Engel and his Liaison Group colleagues felt ready in the sixties to stride onto the national and international stage. Recognized at the beginning of the decade with a Career Research Award from the National Institute of Mental Health, Engel remained the central figure, contributing significantly to two major areas: the specialized field of psychosomatic research and general internal medicine. Within the psychosomatic field, Engel developed new theories of hysterical conversion phenomena and the disease onset situation and offered them as alternatives to the (primarily Alexandrian) psychosomatic orthodoxies of the day. Within medicine more broadly, he roamed widely, from critiques of current educational methods to searching examinations of the deficiencies in contemporary clinical practice.

     Engel foreshadowed much of this new work in 1962 when he published Psychological Development in Health and Disease, a monograph outlining his own psychoanalytically-grounded psychobiological system. Psychological Development was also a textbook based on his lectures – now considerably refined and expanded – regularly delivered to second year medical students. The meatiest parts of the book were the last two chapters, on the somatic consequences of “compensated” and “decompensated” psychological states, about which Engel presents a complex and original synthesis of ideas derived from Freud, Walter Cannon, Hans Selye, and the Rochester Liaison Group.

     Engel then put these ideas on the national and international stage, beginning in 1965 and 1966. At meetings of the American Psychoanalytic Association, the American College of Physicians, the Royal Society of Medicine in London, among others, he presented papers exploring his new ideas about conversion and the disease onset situation. He drew upon his own clinical work plus a careful review of the literature to probe more deeply into the ways in which conversion mechanisms are not, as for Alexander, “bounded by neuroanatomy” but may involve any parts or systems of the body having the “capability to achieve mental representation.” Engel included clinical cases involving the skin, the upper respiratory tract, and the upper and lower gastrointestinal tract to illustrate how remembered “perceptual gestalts” could be the symbolic core of conversion reactions, often determining the timing and location of a broad range of somatic manifestations. In many instances, these somatic manifestations might be complicated by associated physiological or biochemical events following as natural but psychologically meaningless sequelae.

     Engel also relied on his own and Schmale’s work to help sort out the psychological circumstances or “life settings” in which diseases generally had their origin. Rejecting Alexander’s personality-based “specificity” notions, he focused instead on a non-specific onset situation, a psychological complex of “giving up-given up” characterized by the affects of helplessness and hopelessness, which significantly “contribut[es] ... to the emergence of somatic disease ... if the necessary predisposing factors are also present.” After real, threatened or symbolic psychic losses, many but not all patients experience feelings of helplessness and hopelessness and, when they do, diseases or exacerbations of various kinds often soon follow. Presumably because the psychobiological mechanism leading to further, as yet unspecified physiological and biochemical consequences has already been triggered, persons who “give up” become more vulnerable to pathogenic influences in the external environment or derangements in the internal one.

     In 1967 George gave the keynote address to the annual meeting of the European Psychosomatic Society and used the occasion to advertise the work of the Rochester group on the “chronological relationship ... between disease and a psychological complex we are calling ‘giving up-given up.’” He identified the work in which he and his colleagues were engaged as potentially the most fruitful that could be pursued in the psychosomatic field.

For the time being I believe the most useful access to the psychosomatic interface is through discovery of simultaneity or sequence of psychic and somatic phenomena, inadequate as that may be. And the most pressing task is to study with the greatest care and in the finest detail the characteristics of the psychic processes occurring in such time periods of simultaneity or sequence. ... Accordingly, at this time I think refinement of psychological techniques is much more important for us than refinement of physiological techniques. The less instrumentation we place between ourselves and our patients at this time the better, for it serves to complicate the relationship and blur psychological observation.

     Speaking before a larger and more general audience the following year, on April 4, 1968 George delivered the William Menninger Award Lecture to the annual meeting of the American College of Physicians, held that year in Boston in conjunction with the Royal College of Physicians of London. Soon published in the Annals of Internal Medicine as “A Life Setting Conducive to Illness: The Giving-Up – Given-Up Complex,” Engel’s Menninger Lecture broadcast his ideas of disease onset in internist-friendly and psychoanalytically muted terms.

                        Slide 10 – Engel’s paper in Annals

It is no wonder that Chase P. Kimball, in his overview of “Conceptual Developments in Psychosomatic Medicine: 1939-1969" published two year later in the Annals, called Engel and the Rochester group one of the major “schools” in modern psychosomatic medicine and devoted a full quarter of his review article to detailing its clinical and conceptual work.

     George drew confidence for his appearances in the national and international medical spotlight from his solid grounding in Rochester, which grew even more solid in the sixties. As in the fifties, the teaching of interviewing skills was still begun in the first year of the medical curriculum, and Engel’s course on “Medical Psychology and Psychopathology” was a mainstay of the second year. But a reform of third year teaching implemented in 1966 institutionalized George’s psychobiological approach even more completely in the Rochester curriculum. This was the development of a General Clerkship as an innovative, interdepartmental introduction to the series of departmentally-based clerkships that defined the third year. Spearheaded by Dr. William Morgan, recruited to the Department of Medicine in 1962, and by Engel, the complex and faculty-intensive new course consisted of two major phases of closely supervised training. During the first, five-week phase students learned techniques of physical examination and history taking; during the second, six-week phase they progressed to “graduated patient responsibility” under the guidance of a preceptor. Especially important in the new clerkship were the expanded role of the Liaison Group and the corresponding emphasis on interviewing, psychological parameters of illness, and the process of clinical reasoning. Morgan and Engel produced a new teaching manual for the clerkship emphasizing these skills, which was first available in mimeographed form and subsequently published in 1969 as The Clinical Approach to the Patient. Well beyond the weekly liaison rounds still run by Engel’s fellows during the medical clerkship, all students were now thoroughly exposed at the gateway to clinical medicine to “the numerous psychological facets of illness among the nonpsychiatric population.” In Rochester, Engel’s psychologically-oriented approach was so thoroughly integrated into the curriculum that it was indistinguishable from learning clinical medicine as such.

     When the seventies began, George was thus in very high gear. The Clinical Approach to the Patient received a dual rave review in the Annals of Internal Medicine, where it was praised by one reviewer as “a milestone in clinical medicine” and by the other (an editor of the journal) as a “medical classic.” George was much in demand as a distinguished lecturer. He was, for example, the Edward Weiss Lecturer at Temple University School of Medicine in 1975, and the Samuel Novey Lecturer at Johns Hopkins in 1976. Engel used these occasions to address fundamental clinical issues such as the need for closely attentive and rigorously scientific observation of the individual patient’s psychodynamics and the importance of psychological stress in variously precipitating, in different patients, vasodepressor syncope, life-threatening cardiovascular episodes, or sudden death. He also discussed these and related issues as a keynote speaker and named lecturer at medical society meetings and in other honorific settings.

     As the seventies unfolded, however, the ground under Engel began to shift. Notable changes overtook several major fields of medicine, and these changes had important effects on George’s work and influence. Most significantly, psychiatry and internal medicine underwent dizzying and dramatic shifts. In psychiatry, the seventies were marked by the rapid decline of psychoanalysis (which really began in the sixties), the rise of the neurosciences, and the general advance of an aggressive new biological psychiatry.

                        Slide 11 – Solomon Snyder’s diagram in Scientific American

In internal medicine, several large, interrelated shifts also became apparent. Departments of medicine felt themselves reeling in “future shock” as they struggled with unsettling changes in size, subspecialty fragmentation, geographic dispersion, and administrative balkanization. Tied to these changes were further transformations: the displacement of physician-investigators by Ph.D.-trained biomedical scientists; the refocusing of research from human subjects and disease processes to “basic” and increasingly molecular events; and the alteration of study designs from selected patient cases to biostatistically refined clinical trials. The cumulative impact of all these changes was readily apparent in the medical textbooks of the seventies, especially in chapters on diseases long thought to have particularly clear psychosomatic components. A comparison of the chapters on asthma and ulcer in the 1971 and 1979 editions of the Cecil-Loeb Textbook of Medicine, for example, readily reveals a dramatic decline in psychosomatic orientation distilled into the following comment in the 1979 edition: “Much has been written about a possible psychogenic basis for asthma. More often than not, however, emotional problems prove to be a result rather than a cause of the disease.” In short, the audience in mainstream medicine for Engel’s clinical and scientific work shrank dramatically as the seventies progressed and seemed threatened with disappearance by the decade’s end.

     George was also denied the opportunity to retreat to the “safe haven” of psychosomatic medicine, because that field, too, was undergoing disconcerting changes. From Engel’s point of view, the problems of psychosomatic research – already evident in the sixties – deepened in the seventies as animal “models,” “stress” studies, and psychoendocrine bench research took over a larger and larger portion of the field and tended to displace earlier, psychoanalytically-grounded clinical studies. During Herbert Weiner’s tenure as editor of Psychosomatic Medicine from 1972 to 1982, the journal published many more studies of the kind George found disconcerting. Moreover, Weiner’s 1977 Psychobiology and Human Disease emerged as the dominant book in American psychosomatic studies of the decade, and its approach – based largely on neuroscience – gave little solace to Engel, none of whose recent work shared this characteristic.

                        Slide 12 – Weiner’s 1977 Psychobiology

     Because by the latter part of the seventies he was no longer at the forefront of clinical and scientific research in medicine, psychiatry, or even psychosomatics, George increasingly assumed a new role. He became primarily a spokesman for what Alvan Feinstein in 1970 had labeled “clinical exhortation,” that is, the principled assertion of “the importance of patients and of attention to clinical phenomena in the medical world of modern science.” Feinstein introduced this sardonic terminology after reviewing marked trends toward basic and molecular research at the annual meetings of the American Society for Clinical Investigation and the Association of American Physicians in the period 1953-1969 and noticing the disconnect between what research papers actually contained and what leaders of these organizations said in their presidential addresses. Papers were becoming narrower and more reductionist, but presidents were waxing eloquent about old-fashioned clinical virtues.

     With the changes underway in the seventies, George steadily assumed or was pushed into the role of “clinical exhortor.” Then, in 1977, he heightened the intensity of his exhortation by beginning to appeal to a comprehensive, “biopsychosocial model” as an alternative to the narrow and restrictive “biomedical reductionism” that had become dominant in medicine.

                        Slide 13 – Engel’s 1977 Science paper

As he had done earlier in his career but now with a greater sense of urgency, Engel challenged reigning medical orthodoxy – governed, he claimed, by a “paradigm” that had hardened into a “dogma.” He called for the adoption of a broadly inclusive, “systems”-based, intellectual framework that legitimated, among other things, the paying of close attention to the patient’s social needs and emotional realities and the training of a new generation of “biopsychosocial” clinicians.

                        Slide 14 – Engel’s 1980 “Clinical Application” paper

     Although he struck a resonant chord with many and got considerable praise and attention for his biopsychosocial model, George’s new exhortatory role had its limitations. He was still highly visible and, by some, even more enthusiastically applauded than before, yet his strongest sympathizers acknowledged that his alternative model sometimes received “lip service” rather than true support and predicted that real acceptance “may be long in coming.” All this was made abundantly clear in the ulcerative colitis chapter in the 1979 edition of the Cecil-Loeb Textbook of Medicine. In contrast to the chapter in the 1971 edition which still gave considerable credence to George’s ideas, the chapter in the later edition dismissed his approach with the comment: “[R]ecently, these [psychosomatic] concepts have been both challenged and ignored by workers in the field.” Adding insult to injury, the author of the 1979 chapter misspelled Engel’s name twice. Yet Engel’s “Biopsychosocial Model” was a rallying cry for many, not least in Rochester, where it stood for the best in humanistic and psychosocially sensitive medical education and multidimensional clinical care.

     But it is fair to note that, even in Rochester, the Biopsychosocial Model has had some difficult moments in the 21 years since George stepped down as Director of the Medical-Psychiatric Liaison Group. On the one hand, the development of psychoneuroimmunology by Bob Ader, Nick Cohen, David Felten and others has provided a brilliant new research foundation for many of the clinical insights of the biopsychosocial approach.

                        Slide 15 – Ader’s 1981 PNI book

The approach has also remained firmly ensconced in first and second year teaching, even if it has lost some ground in the General Clerkship and in the third and fourth year clinical curriculum more broadly. Yet the Liaison fellowship program disappeared from Strong in the eighties and was only resurrected, after a struggle and in modified fashion, at Genesee and Highland hospitals. In the early nineties, Tim Quill, Tony Suchman and Rich Frankel built a new Program in Biopsychosocial Studies around that revived and remodeled fellowship program, and in the later nineties members of the Program played a very active role in the Medical School curriculum, both before and after the adoption of the “Double Helix” innovations. The Biopsychocial Model has come a long way from its psychoanalytic and psychosomatic roots, but it seems destined to stay as part of Rochester’s medical environment. George would be proud.





Copyright: The Author

Department of History

University of Rochester

Rochester, N. Y.

http://www.history.rochester.edu