This week I have been queuing up ideas around how my approach to therapy might fit with a description of bio-psycho-social-spiritual; building on the ideas of Engel (1977) who first proposed the “biological, psychological, and social, must be taken into account in every health care task”. A philosophy of clinical care (a way of understanding how suffering, disease, and illness are affected by multiple levels of organization, from the societal to the molecular), Engel’s model is also a practical clinical guide (a way of understanding the patient’s subjective experience as an essential contributor to accurate diagnosis, health outcomes, and humane care; Borrell-Carrió et al. 2004). Saad et al (2017) report the growing momentum to add the fourth, spiritual, dimension to considerations of well-being, narrowly (and controversially) missing inclusion in the WHO statement of health as not merely being the absence of disease: More positively defined, well-being is a “completeness” to which all four dimensions are necessary. What is arguably critical is to define “spiritual” so it becomes palatable and inclusive in an increasingly “contemporary pluralistic society and individualistic culture” (Saad et al 2017). Across the care professions, the biopsychosocial model has been adopted for its holistic view of human being. The addition of the spiritual makes sense to the humanistic practitioner if we define spirituality as “the search for ultimate meaning, purpose and significance, in relation to oneself, family, others, community, nature, and the sacred, expressed through beliefs, values, traditions and practices” (Puchalski et al., 2014); indeed, so much of our work with clients is about a search for meaning. When I first came across the Tidal model of recovery, I was struck by Barker’s (2001) description of care work as being akin to spiritual friendship, “predicated on a kind of confession (of vulnerability) within an intimate conversation”; a phrasing that doesn’t look too far from Buber’s dialogue.
I needed some time to feel my way into the direction of this piece. A pause because there was something sensitive and nuanced that wanted to be known, articulated. A question: how to speak to the whole and the parts in a way that doesn’t prioritise one over the other? I can’t write about them simultaneously, but as I sit here (and, as a more holistic practitioner I give credence to), I am experiencing across all levels. To describe things to you, it is easier to compartmentalise. I guess this is the crux of the issue. I am hoping by making this nuance of the lived explicit, you will allow me to break things down into what is not breakdown-able!
The whole is always greater than the sum of its parts; or as Van Deurzen repeatedly expresses in her four worlds of physical, social, personal, and spiritual dimensions (2018), “Life is never simplistic or binary. It is always complex and multiple. Neither dualism nor materialism or idealism can ultimately satisfy any who are challenged by their own existence. Soon enough, we discover that life is multi-layered and that many things at many levels are interconnected in complex ways” (2018). To understand the complexity of the murmuration, we might usefully consider the simplicity of the starling: just like the isolated self is a convenient fiction in service of understanding intraconnection, there is a parallel by looking at the discrete aspects of each dimension to understand how they are always weaving together. When I look at my career path to date…..
My original training was as a physiologist; while it is a world I am glad to have left, I can’t really ever leave it behind. On the pragmatic level, I appreciate my learning of physiology as it helps me honour the organism of the individual; that chemicals are related to affect, that what we eat and how we move impact our well-being. Think of our clients with insomnia: isn’t there a worth in encouraging those basic checks of their sleep hygiene? Or the client who reports palpitations, why not suggest they get a medical? Certainly, to know the biology of menopause is a great support to female clients through mid-life. I would also advocate any therapist gaining the fundamentals of neuroscience and neurobiology: to truly know the bases of body as it appears in its physical manifestation (note to types of body) is to be able to critically integrate the techniques and theory we know to have great efficacy: e.g. EMDR, somatic experiencing, polyvagal. I would particularly encourage the humanistic psychotherapist to explore interpersonal neurobiology: its model can help us investigate more layers within the dimension of the biological organism in a way that doesn’t jar with our humanistic sensibilities: the layers of narrative that are verbal, somatic, neuroceptive (Carter, 2023). To know something of biology (whilst knowing its limits) can only support the more existential-phenomenological explorations concerning “our physical embeddedness in a world of things where we find our bearings through our five senses and struggle with the contradictions of life and death, health and illness, pleasure and pain, harmony and chaos” (van Deurzen, 2018).
I make no secret of being a psyche-naut (Carter, 2023). Whilst this fascination is predominantly a curiosity about the subjective experiencing of mind from within, I also value the study of mind from without. Indeed, I state in the book I am writing now that I am one humanistic practitioner who appreciates what the field of humanistic psychology has brought to our practice. Engel’s biopsychosocial model and its literature might tend toward descriptions of mind and emotions from the psychological; an existential writer like van Deurzen prefers to speak of the personal dimension, one in which a sense of self is being created “out of a constantly changing landscape of personal and psychological experiences and capacities, modulated by our thoughts as we contend with strengths and weaknesses, confidence and confusion, perfection and imperfection, identity and freedom” (2018).
According to van Deurzen, “our social situatedness in a world with other people, where we orientate ourselves with the help of our feelings” is where we are called to “contend with the contradictions of love and hate, belonging and isolation, dominance and submission, acceptance and rejection” (2018). I recall my experience of the pandemic being an alchemical boot camp! A global wide experiment where the sudden fracturing of our social world revealed an opportunity to deeply examine my relation to being a-part and apart: to be locked-down and isolated and yet fully aware of how my actions and choices impacted on others, strangers and intimates. It was a period that helped me to know, and honour, the introverted aspects of me and yet to be more available and vulnerable with my close circle. We have already named some approaches that hold our situatedness to the fore (e.g. genogram, or Bronfenbrenner’s ecological model).
It is perhaps natural that this being-in-the-world so committed to ‘waking up’ to an inherent wholeness will frame the humanistic approach as biopsychosocial-spiritual As I am advocating in this text, to include this latter dimension doesn’t require a religious path: the broader sense of spiritual includes the “ontological relationship to the meanings and purpose of life, where we find our direction by intuition, making sense of the contradictions and paradoxes of good and evil, truth and untruth, right and wrong, meaning and futility” (van Deurzen, 2018). The spiritual dimension invites us to appreciate our interconnectedness: whether that be as a therapist to have faith that working with one person will change the world (as per the dictum of anthropologist Margaret Mead) quite literally. When we realise an intraconnection, why would we not consider how our behaviour impacts planet Earth. Writing this just days after her death, I cannot help but cite Joanna Macy’s work regarding climate change and crisis (Macy and Johnstone, 2012). This is also the realm of rites of passage: another form of spiritual development to consider in client work involving life-change transitions.
As I write this essay, I am recovering from a cold. That is both true and incomplete. More precision would be to say, as I write this I feel listless, a kinda emptiness that is full. Drained because of so much. Yes, on the physical level I have had a cold; and yet also there is psychological context of my father’s ill health and its emotional impact; I would add the social dimension of engaging with the organisations and institutions that govern his care alongside how I am reaching to more personal aspects of the social; and there is the loss of spirit that a physical lack and emotional plenty have coalesced. I was sharing with a friend last night how not so long ago, I would be trying to tease out what is causing what; but rather than the pursuit of why, a switch to the what and how of my experiencing is more helpful. The sum of these bio-psycho-social-spritual parts is more than each, alone. It is the same friend with whom I have been studying Gendlin’s process model as part of a CPD programme; to be able to share my experiencing as multifaceted is through an appreciation of Gendlin’s inter-affecting (2018). That while we separate out layers and parts of a system, this is for convenience and practical reasons.
We are always situated in a particular time and place. We are always making something of what has been made of us, as Sartre (1960) and Merleau-Ponty (1962) both pointed out. It is helpful to have a model that reminds us of the complexity of life so that we can check how a person is constantly creating and changing meanings at many different levels. Yet a model is just that. The four worlds model is not hierarchical and makes no claims for being an accurate representation of human reality (Van Deurzen, 2018); and the same might be said for the Tidal model of recovery that is also aiming to put subjectivity back at the core of care (Barker, 2001). Models are “a simple heuristic device to allow us to conceive of the layered nature of human existence and its paradoxes” (Van Deurzen, 2018). A model can help us to remember the facets that make the whole: that my current listlessness is predicated upon multiple layers that need my attention. Similarly, a client can learn to scan what might be operating out of awareness.
As I was making way for my listlessness to express this morning, I was doing some light yoga, feeling into the needs of my interconnected-being. In one of my poses, a title on the spine of a book jumped out at me, Dzigar Kongtrul’s Training in Tenderness. I suddenly found uplift in my pose and in my listlessness: bringing to mind the day of writing ahead what had felt like a fulfilment of a regular, weekly ritual became in-spired with breath. I needed tenderness today, a nursing that included and valued all of my experiencing. I finished my yoga, showered, and allowed the inspiration to carry me to my local cafe to write. The four levels presented here are what allows tenderness. I again recollected last night’s CPD session with my friend: specifically, how Merleau-Ponty’s work on primordial contact has been described as “the kiss of the world” (Kennedy, 2013). Self, with its layers of bio-psycho-social-spiritual is but a fractal of the flesh of the world: an in-here lived out-there (and vice versa). To allow the world to touch us, move through us, is to acknowledge our contingent and coextensive nature. I belong in the world because I am of the same stuff. Paying attention to our embeddedness in the spirit of William Blake (Vernon, 2025) is to allow the tender kiss, to be both embraced and embracer.
Our work with clients requires that we keep in mind our client’s well being across and within all four: and like the invitation to reflect upon integration and eclecticism, it might be worth considering too how one sits with multidisciplinary and interdisciplinary ways of working. Like Barker (2001) speaks to in the Tidal model, a respectful approach to addressing the lived experience of the person and their significant others is to offer “multidisciplinary assistance, under an interdisciplinary logic”*. To be a humanistic practitioner invites or rather requires the capacity to hold in awareness all dimensions for well-being: to help our clients find efficacy in the physical world, to be of value in the social world, to find a sense of self-worth in their inner world, and to gain purpose through the spiritual (Baumeister, 1991). We are also there to assist the weave of the polarities within. For instance, to be equal to the paradox of potential for meaning making through the limiting forces of the ultimate concerns of our existence (Greening, 1992); and, furthermore, to be able to critically integrate subjective and objective perspectives on well-being.
*Multidisciplinary involves separate disciplines working on a problem, often independently, while interdisciplinary involves integrating knowledge and methods from different fields to create a more cohesive and unified approach
References:
Barker, P. (2001). The Tidal Model: developing an empowering, person‐centred approach to recovery within psychiatric and mental health nursing. Journal of psychiatric and mental health nursing, 8(3), 233-240.
Baumeister, R. F. (1991). Meanings of life. London, UK: Guildford Press.
Borrell-Carrió F., Suchman A.L., Epstein R.M. The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry. Ann. Fam. Med. 2004;2:576–582. doi: 10.1370/afm.245.
Engel, G. L. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196(4286), 129-136.
Gendlin, E. (2018). A Process Model. United States: Northwestern University Press.
Kennedy, D. J., Kennedy Phd, D. J. (2013). Healing Perception: An Application of the Philosophy of Merleau-Ponty to the Theoretical Structures of Dialogic Psychotherapy. Australia: CreateSpace Independent Publishing Platform.
Kongtrul, D. (2018). Training in tenderness: Buddhist teachings on tsewa, the radical openness of heart that can change the world. Shambhala Publications.
Macy, J., Johnstone, C. (2012). Active Hope: How to Face the Mess We’re in Without Going Crazy. United States: New World Library.
Merleau-Ponty, M. (1962). Phenomenology of perception (C. Smith, Trans.). London, UK: Routledge. Sartre, J. P. (1960). Critique of dialectical reason (A. Sheridan-Smith, Trans.). London, UK: Verso.
Puchalski C.M., Vitillo R., Hull S.K., Reller N. Improving the Spiritual Dimension of Whole Person Care. J. Palliat. Med. 2014;17:642–656.
Saad, M., De Medeiros, R., & Mosini, A. C. (2017). Are we ready for a true biopsychosocial–spiritual model? The many meanings of “spiritual”. Medicines, 4(4), 79.
van Deurzen, E. (2018). The search for existential meaning [keynote presentation]. International Network on Personal Meaning conference, Vancouver, Canada.
Vernon, M. (2025). Awake!: William Blake and the Power of the Imagination. Oxford University Press.