Biopsychosocial Approaches

Systems change as a function of both the forces acting upon them and their own internal dynamics. The same is true for a switch from a non-depressed to a depressed state (Gilbert, 1984). There is now increasing recognition that depression is typically related to a host of interacting processes in the domains of physiological processes (genes and stress hormones), psychological processes (negative beliefs, rumination, and social withdrawal), and social factors (life events and social support) that interact over time (Akiskal & McKinney, 1975). This is depicted in Figure 6.1.

Note the ongoing, dynamic, and reciprocal nature of these interactions. Thus, one's early life (for example, love or abuse) interacting with genetically given temperament will affect physiological processes, social behaviour, and the schema of relationships. Thoughts and

Physical Ecologies:

Resource scarce versus resource plenty

Hostile versus and benign

Social Ecologies:

Cooperative versus competitive

Caring versus exploitative/hostile

Figure 6.1 Biopsychosocial and ecological interactions beliefs about relationships (such as fear of abandonment) can reflect and affect physiological process and social behaviour. Manifest social behaviour (for example, clingy attachment or quickness to take offence) can mean that relationships are stormy and break up easily, affecting physiology (such as stress hormones), relational schema, and social behaviour. These biopsychosocial relations are themselves contextualised in different types of physical and social ecologies. Not only are interactions key to understanding the emergence of states such as depression, but also there can be discontinuities in each domain. For example, there may be genetic or early sensitisation effects that increase the instability of key neuronal affect modulators. Or consider how Beck (1967, p. 277) described the vulnerability of negative latent schema that can persist 'like an explosive charge ready to be detonated by an appropriate set of conditions'; explosions are hardly smooth transitions. And, of course, in the social domain, life events can be sudden (such as the death of a loved one, the break-up of a relationship, or serious illness or injury). Understanding interacting processes that produce discontinuities and state shifts are, then, often the rule rather than the exception.

Early forerunners of the biopsychosocial approach can be found in Meyers' psychobiol-ogy approach (Rutter, 1986), behavioural medicine, and psychosomatic medicine (Kiesler, 1999). The biopsychosocial approach is critical of narrow-focused or single-process approaches and is critical of 'the dualisms' (mind versus body; nature versus nature)—which Eisenberg (2000) aptly termed 'brainless and mindless science'—that still plague our theorising. One thing is clear, however; that although many clinicians of all types pay lip service to a biopsychosocial approach, few actually adopt it in their clinical practice or research. The main reasons are that clinicians do not understand it and rarely study interactions of processes, and so radical shifts in research, training, and practice are needed (Kiesler, 1999).

Given the high incidence and prevalence rates of depression, it is not surprising that there have been a vast number of theories about the vulnerability, onset, and maintenance factors (Gilbert, 1992). As will be noted below, these focus variously on genetic vulnerabilities, acquired vulnerabilities (for example, via aversive early life experiences), and/or current social contexts. Despite our long recognition that the study of ongoing, reciprocal, dynamic processes of individual-environment interactions is central to understanding states such as depression (Akiskal & McKinney, 1975), many theories of psychopathology, let alone depression, rarely address issues of complex biopsychosocial interactions (Eisenberg, 2000). Many have lamented the way social and biological theories often operate in isolation from each other (Cacioppo et al., 2000), and studies are often on groups, thus losing in the variance the individual nature of interactions. It is, however, true that many theorists of major depression endorse some form of a stress-diathesis model, which suggests that stressors affect underlying vulnerabilities (e.g., Akiskal & McKinney, 1973; Hankin & Abramson, 2001).

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