Psychosomatic medicine (Uexküll) and the biopsychosocial model (Engel)

1. Introduction

Version followed: George Engel's biopsychosocial model as set out in Engel (1977, Science) and Engel (1980, Am J Psychiatry), read through the practice principles of Borrell-Carrió, Suchman and Epstein (2004); Thure von Uexküll's "integrated medicine" (Situationskreis, individual reality); and the German psychosomatic care model as currently described by the specialist societies (DGPM/CPKA/VPKD position paper, 2024), Kruse (2015/2017), the S3 guideline Funktionelle Körperbeschwerden (AWMF 051-001, 2018; short version Roenneberg et al. 2019), a 2026/27 university curriculum for Psychosomatische Grundversorgung, and a university inpatient programme brochure (Heidelberg, 2020). The 4P formulation grid is a later teaching tool, not Engel's own [source: PsychDB].

What it is. This is a framework for understanding and organising care, not a single psychotherapy. It tells the therapist how to assess, formulate, communicate and collaborate when bodily symptoms, physical illness and psychological and social life are entangled; the actual psychotherapy delivered within it is a recognised method (CBT, psychodynamic therapy, hypnotherapy and others) chosen for the indication [source: S3 Funktionelle Körperbeschwerden; Borrell-Carrió et al. 2004].

• Engel (1977). Engel argued that the dominant biomedical model left no room for the psychological and social dimensions of illness and proposed "a biopsychosocial model" as "a blueprint for research", teaching and health care [source: Engel 1977, PubMed abstract]. He criticised mind–body dualism, reductionism and the idea of the detached observer, drew on systems theory, and rejected purely linear cause–effect thinking in favour of interacting levels and circular (feedback) causality; he did not endorse "holistic-energetic" views of illness [source: Borrell-Carrió et al. 2004]. In 1980 he applied the model to a medical (not psychiatric) patient with acute myocardial infarction to show the unity of medicine [source: Engel 1980 abstract].
• Uexküll. Thure von Uexküll (1908–2004), an internist, held the Ulm chair of internal medicine and psychosomatics (1966–1976), edited the Lehrbuch der psychosomatischen Medizin (1979; titled Psychosomatische Medizin from the 3rd edition, 1986), wrote Theorie der Humanmedizin with Wolfgang Wesiack (1988), founded the DKPM (1973) and the Akademie für Integrierte Medizin (1992) [source: NDB/Deutsche Biographie]. He aimed to overcome "the present dualism of a medicine for soulless bodies and a medicine for bodiless souls" (translated from the German quoted in NDB). With Wesiack he sketched the Situationskreis (situation circle, 1986), a cybernetic model of how a person interacts with his or her environment, built on his father Jakob von Uexküll's Funktionskreis [source: NDB]. Each person lives in an "individual reality"; a shared reality between clinician and patient is the prerequisite for a diagnostic and therapeutic alliance, and patients should be allowed to describe their own theories of their illness [source: Atarodi et al. 2014, interview-based account].
• German specialty. Basic psychosomatic care (Psychosomatische Grundversorgung) was introduced in 1987; a medical specialty "Psychotherapeutische Medizin" was created in 1992 and later renamed "Psychosomatische Medizin und Psychotherapie" [source: Kruse 2015/2017] (year of renaming [uncertain: not verified]). Uexküll himself had not intended psychosomatics to become a separate specialty [source: Atarodi et al. 2014].

How change happens. Illness and suffering arise and are maintained by interacting biological, psychological and social processes; change comes from (1) assessing all levels at once, (2) building with the patient a shared, non-blaming explanatory model in which psychosocial factors are conditions, triggers or amplifiers rather than "the cause", (3) a reliable, trusting relationship, and (4) coordinated care in which medical and psychological treatment run side by side [source: Borrell-Carrió et al. 2004; S3 Funktionelle Körperbeschwerden; Atarodi et al. 2014]. Psychotherapy within this framework is psychological care alongside medical treatment; it is not a treatment for cancer, heart disease or any other physical disease [synthesis].

2. Framework

The sources do not prescribe numbered phases for the biopsychosocial model itself. The phase structure below is assembled from the S3 guideline's stepped-care model and its named phases ("Simultandiagnostik"; "Vom Erklärungsmodell zur Bewältigung") and from the German care levels [source: S3 Funktionelle Körperbeschwerden; synthesis for the ordering].

Phase A — Engagement and simultaneous assessment

• Goal: establish trust; assess bodily, psychological and social aspects at the same time and with equal weight ("Simultandiagnostik"); identify warning signs of dangerous courses ("red flags") and risk factors for chronicity ("yellow flags") [source: S3].
• Format: individual sessions; collateral contact with the GP or treating physician with consent [synthesis]. The guideline notes that this kind of assessment can itself be therapeutic [source: S3].
• Move on when: medical assessment is in hand with the responsible physician, and enough history exists to draft a formulation [synthesis].

Phase B — Formulation and shared explanatory model

• Goal: a written biopsychosocial formulation (e.g. 4P × bio/psycho/social grid) and an individual explanatory model developed jointly with the patient, such as a vicious-circle model [source: PsychDB; S3].
• Move on when: the patient can state, in his or her own words, a model that includes the body and does not feel blamed [synthesis].

Phase C — Stepped treatment

The S3 guideline describes three steps; earlier steps remain valid when later ones are added [source: S3]:

1. Initial basic care (early contact): basic diagnostics, advice, reassurance; encouragement towards an active lifestyle, ideally drawing on activities the person once found helpful.
2. Extended basic care (persistent, distressing complaints): regular appointments independent of the current symptom level, calm setting, careful repeat diagnostics at intervals, joint realistic small-step goals and wider values; active strategies (physical activation, re-exposure where the person avoids or spares themselves, self-help literature and groups) are preferred over passive symptom relief, which is regarded as temporary.
3. Multimodal treatment, psychotherapy and rehabilitation (severe courses): indicated by marked impairment or high use of health services; psychotherapy indicated by relevant psychosocial stress, mental comorbidity, dysfunctional illness beliefs, marked impairment or difficult clinician–patient relationships; CBT, psychodynamic psychotherapy and hypnotherapy are named as well founded; building motivation for therapy is an early goal; day-clinic or inpatient treatment is considered when outpatient care is impossible or insufficient; rehabilitation when participation and work capacity are the focus.

Phase D — Coordination, consolidation and ending

• Goal: keep one coordinating physician (the GP or somatic specialist keeps a "gatekeeper" role), a stable outpatient network, and step-down after intensive treatment [source: S3; DGPM/CPKA/VPKD 2024].
• End or step down when: goals are met, the patient manages fluctuations without escalating care, and follow-up with the GP is arranged [synthesis].

Session counts and settings

• The sources give no fixed number of psychotherapy sessions for this framework [uncertain]. Outpatient psychotherapy length follows the chosen method and payer rules [synthesis].
• If needed, the guideline suggests a re-presentation appointment with the physician in two to four weeks in early care [source: S3].
• Example inpatient programme: about 8 weeks, with the first two weeks as a trial and orientation phase; short 3-week crisis stays also offered [source: Heidelberg Station Mitscherlich brochure, 2020].

The German care levels (where a referral can go)

Psychological psychotherapists also treat these patients in Germany; their place in this structure is not described in the sources above [uncertain: not verified].

3. Guiding principles

From Engel [source: Borrell-Carrió et al. 2004 unless noted]

• No mind–body split. Practical meaning: never sort a symptom into "physical" or "psychological"; ask how both are involved.
• No reduction to one level. Mental and social phenomena depend on the body but cannot simply be reduced to it; take subjective experience seriously as data.
• The clinician is a participant, not a detached observer. Your own reactions are part of the clinical field; use and check them.
• Interacting levels and circular causality. Look for feedback loops that keep a pattern going.
• Balance circularity with linear approximations when planning. The 2004 authors' refinement: for decisions, pick a workable sequence of targets.
• Not holistic-energetic. Engel did not treat physical illness as something healing energies can control; do not imply that psychological work cures physical disease.

From Uexküll [source: Atarodi et al. 2014; NDB]

• Individual reality. Each patient experiences the illness within a personal world of meanings; find out what it means to this person.
• Shared reality first. Diagnosis and treatment depend on building a common understanding; do not move to interventions before it exists.
• Let patients tell their own illness theory. Ask, listen and use their words.
• Integration rather than splitting. Body care and mind care are one task; coordinate rather than hand over.

Practice pillars proposed by Borrell-Carrió, Suchman and Epstein (2004) (their proposals, not Engel's)

• Self-awareness. Notice your own habits and feelings in the encounter; mindfulness supports this.
• Active cultivation of trust. Cordiality, genuineness, optimism, humour; meet hostile patients with respect.
• Empathic curiosity. Keep a "beginner's mind"; do not label patients "good" or "bad".
• Self-calibration to reduce bias. Check how race, sex and premature closure shape your decisions.
• Educating the emotions. Learn to tolerate uncertainty.
• Informed intuition. Trace a gut doubt back to concrete observations.
• Communicate evidence in dialogue. Give information in small, digestible pieces; avoid overload.
• Autonomy in relation. Most patients want information but few want to decide alone; share decisions rather than abandoning the patient to "autonomy".
• Do not push your social agenda. Social-change goals pursued before the patient agrees become a "political battleground".

From the German S3 guideline [source: S3 Funktionelle Körperbeschwerden]

• "Both-and" perspective (Sowohl-als-auch). Consider bodily and psychosocial aspects from the very start, not psychological factors only after tests are negative.
• Reassure without trivialising. Convey that the complaints are credible without denying or minimising them, even before a diagnosis is named.
• No monocausal explanations. Frame stress as conditions, triggers, amplifiers or "additional building sites", not as causes.
• Restraint with diagnostics. Avoid repeated, especially invasive, tests whose main purpose is reassurance; announce necessary ones calmly.
• Watchful openness (abwartendes Offenhalten). Without warning signs, convey that improvement is likely and keep observing.
• Keep watching red and yellow flags. Reassess throughout care.
• Clinician behaviour shapes the course. The guideline states this explicitly; your stance is an intervention.
• Reliable contact not tied to symptoms. Regular appointments, independent of how bad the symptoms are this week.
• Active over passive. Favour activation and coping over passive measures.
• One consistent team stance. The whole team handles the patient deliberately and consistently.

Scope [synthesis]

• Psychological care alongside medical care. Never imply that therapy replaces medical assessment or treatment; route every medical question, new symptom or medication issue to the treating physician.

4. Intervention inventory

The inventory has three parts: A. assessment and formulation; B. communication and treatment within the stepped-care model; C. collaboration, the German care pathways (including inpatient programmes) and the clinician's own work. All example wording is illustrative and is the guide's own, not the founders'.

A1. Simultaneous biopsychosocial assessment interview

• Purpose / when: the first sessions with any client whose problem involves bodily symptoms or physical illness; also when a referral arrives framed as "nothing found, please see psychology" [source: S3; Borrell-Carrió et al. 2004].
• Steps:
  1. Start with the body: ask about the main complaints and any further complaints, in the patient's words, before asking about stress [source: S3].
  2. Ask about general well-being, the impact on everyday life and work, and how the person copes with the complaints [source: S3].
  3. Observe behaviour in the session, e.g. anxious avoidance of movement or a dramatic way of presenting complaints, and note it without judging [source: S3].
  4. Map the social field: family, work, finances, supports, recent losses or changes; ask directly and privately about violence or abuse when injuries or unexplained presentations appear (the 2004 authors cite patients who seek care only for bruises) [source: Borrell-Carrió et al. 2004; synthesis for the screening step].
  5. Psychological field: mood, anxiety, illness worries, prior mental health problems, substance use, suicidal thoughts (standard risk assessment) [synthesis; Grundversorgung curriculum covers depression, anxiety, crisis intervention and suicide prevention: UKR 2026/27].
  6. Obtain, with consent, what medical assessment has been done and what is planned; agree who is responsible for further medical investigation [source: S3 (coordination); synthesis].
  7. Screen for warning signs that need prompt medical review (red flags) and for chronicity risk factors (yellow flags); pass red flags on to the physician the same day [source: S3; synthesis for timing].
• Example language (illustrative): "Before we talk about anything else, I'd like to understand the symptoms themselves: where you feel them, when they're worse, what they stop you doing." / "Many people with symptoms like yours are under strain in other parts of life too. That doesn't make the symptoms less real. Could we look at both?"
• Watch for: the patient bracing as soon as stress is mentioned (slow down, return to the body); your own urge to decide "physical or psychological" early; signs of a new or changing medical problem. Working if: the patient talks freely about both body and life, and a joint picture starts to form.

A2. Eliciting the patient's illness theory and individual reality

• Purpose / when: early and repeatedly; Uexküll's precondition for a diagnostic and therapeutic alliance is a shared reality, and patients should be able to tell their own theory of the illness [source: Atarodi et al. 2014].
• Steps:
  1. Ask what the patient thinks is happening, what caused it, what they fear it could be, and what they think would help [synthesis, operationalising the cited principle].
  2. Ask what the symptom means in their life (e.g. "what it says about me", what it prevents, what it protects from) [synthesis].
  3. Reflect the theory back in their words and check accuracy.
  4. Note causal attributions that blame (self or others), e.g. a person attributing a heart attack to a family argument; the 2004 authors caution that such attributions can blame patients or worsen symptoms [source: Borrell-Carrió et al. 2004].
  5. Record where the patient's model and the medical model overlap; build from that overlap.
• Example language (illustrative): "What's your own sense of what's going on in your body?" / "What worries you most that it might be?" / "So in your view, the pain started after the move and got worse when the arguments at home began. Have I got that right?"
• Watch for: a feared diagnosis that has never been spoken (it often drives checking and doctor visits) [synthesis]; theories that load all blame on the patient. Working if: the patient corrects and adds to your summary, a sign that a shared reality is forming.

A3. Mapping interacting levels and feedback loops (systems view)

• Purpose / when: after A1–A2, to see how body, person and social context influence each other, as Engel's systems-based model requires [source: Borrell-Carrió et al. 2004]. Engel's hierarchy runs from biological subsystems through the person to dyad, family and community levels [uncertain: exact list of levels not verified].
• Steps:
  1. Draw levels as stacked boxes (body systems; the person's experience and behaviour; relationships/family; work and community).
  2. Add arrows for observed influences in both directions (e.g. pain → less activity → deconditioning → more pain; illness → role change in the family → conflict → poorer sleep).
  3. Mark circular loops that sustain the problem.
  4. Then, following the 2004 refinement, choose a linear working sequence: which loop to target first [source: Borrell-Carrió et al. 2004].
  5. Use the examples the 2004 authors give as templates, e.g. "Mr J", whose hypertension was linked to salt intake, stressful work, poor support and an over-responsible personality, with a menu of options (medication, diet, stress reduction, psychotherapy) decided jointly with his physician [source: Borrell-Carrió et al. 2004].
• Example language (illustrative): "Let's draw what affects what. You said the pain keeps you home, and being home you think about the pain more. Where does your partner come into this picture?"
• Watch for: a diagram that turns into a single-cause story; arrows that make the patient look culpable. Working if: the patient spots loops themselves.

A4. The 4P biopsychosocial formulation

• Purpose / when: to write the formulation that guides the plan; a teaching tool adapted from Barker (1995) and Weerasekera (1993), not Engel's own [source: PsychDB].
• Steps [source: PsychDB]:
  1. Build a grid: rows predisposing, precipitating, perpetuating, protective; columns biological, psychological, social.
  2. Fill the easier biological and social cells from the history first; psychological cells last.
  3. Leave cells empty if nothing applies; do not force entries.
  4. Write a short narrative (sequential, narrative or chronological style) ending in an integrative statement on how the factors interact, the prognosis and where to intervene.
  5. Link to a plan: level of care (disposition), biological (for the physician; a psychotherapist names questions for the prescriber, never medication changes), psychological (method chosen to fit), social.
  6. Revise the formulation as information comes in.
• Example language (illustrative), sharing a simplified version: "Here's how I'm understanding things so far: some things made you more vulnerable, some set this off, some keep it going, and some are strengths we can build on. Tell me what I've missed."
• Watch for: generic entries that would fit anyone; mentioning trauma without saying how it matters; a "grand unified theory" [source: PsychDB]. Working if: the plan follows from the grid and the patient recognises themselves in it.

B1. Communicating about mind–body links without dismissing symptoms

• Purpose / when: whenever psychosocial factors are raised, especially with functional or persistent bodily complaints [source: S3].
• Steps [source: S3 unless noted]:
  1. Convey credibility: say you believe the symptoms are real and distressing, even before a diagnosis is named.
  2. Reassure without trivialising or negating the complaints.
  3. Use "both-and" language: bodily and psychosocial aspects together.
  4. Describe stress and emotions as conditions, triggers, amplifiers or "additional building sites", not as causes; avoid monocausal explanations.
  5. Explain psychophysiological links concretely (e.g. how tension, attention, sleep loss and avoidance can amplify bodily signals) using a vicious-circle drawing.
  6. Where a physician has given a functional diagnosis, help the patient understand that such diagnoses are descriptive, and that the physician has said the outlook is not life-shortening; do not make medical statements yourself [source: S3; synthesis for the scope limit].
  7. Avoid phrases that imply "nothing is wrong" or "it's all in your head" [synthesis].
• Example language (illustrative): "Your symptoms are real; I'm not doubting that for a moment." / "Stress doesn't create pain out of nothing, but it can turn up the volume on it." / "Your body and your life situation are both part of this picture, and we can work on both."
• Watch for: the patient hearing "psychological" as "imagined" or "weak"; shame; anger at previous clinicians. Working if: the patient uses "and" rather than "either/or" when describing the problem.

B2. Co-developing a biopsychosocial explanatory model (vicious-circle model)

• Purpose / when: after B1, to give the patient a personal model that makes coping strategies make sense; the S3 guideline's phase "from explanatory model to coping" [source: S3].
• Steps:
  1. Pick one recent symptom episode and track it: situation, bodily sensation, thoughts, feelings, behaviour, consequence [synthesis, standard CBT-style episode analysis].
  2. Draw the loop (e.g. sensation → worry → tension and checking → stronger sensation).
  3. Add the patient's own theory and the medical findings to the drawing so nothing is excluded.
  4. Ask where the loop could be interrupted; let the patient choose.
  5. Hand the drawing over; revisit and revise in later sessions.
• Example language (illustrative): "Let's take Tuesday's episode. What did you notice first in your body? And then what went through your mind?"
• Watch for: models imposed rather than built; the model being used later to dismiss new symptoms (any new or changed symptom still goes to the physician). Working if: the patient explains the loop to a family member.

B3. Supporting understanding of findings and planned tests (with the physician)

• Purpose / when: when incidental or minor findings or pending tests feed anxiety; the guideline asks physicians to place such findings in a normalising, lay-friendly way, sometimes in a review conversation ("Bilanzgespräch"), to announce expected normal results beforehand, and to avoid repeated reassurance tests [source: S3].
• Steps:
  1. Ask what the patient was told and what they understood.
  2. If unclear or frightening, encourage and help prepare questions for the physician (written list) rather than interpreting results yourself [synthesis].
  3. With consent, tell the physician which findings are causing fear so the review conversation can address them [synthesis].
  4. Explore what a test would need to show for the patient to feel safe, and whether any test could [synthesis].
• Example language (illustrative): "That's a question for Dr K, and a good one. Shall we write it down so you have it ready?"
• Watch for: you being drawn into giving medical opinions; reassurance-seeking moving from doctors to you. Working if: fewer reassurance visits and questions get answered at source.

B4. Watchful openness and warning-sign monitoring

• Purpose / when: throughout care. Without warning signs, the guideline conveys that improvement is likely and continues observing ("abwartendes Offenhalten"); red and yellow flags are reassessed continuously [source: S3].
• Steps:
  1. Agree with the physician which changes would warrant medical review [synthesis].
  2. Ask briefly each session about new, changed or worsening symptoms.
  3. Route new or changed symptoms to the physician promptly; do not judge them "psychosomatic" yourself [synthesis].
  4. Track yellow flags (e.g. increasing avoidance, withdrawal from work) as therapy targets [source: S3 for the concept; synthesis for use].
• Example language (illustrative): "Anything new or different in your body since last week? If so, that's something for Dr K to look at, and we'll keep working on the rest here."
• Watch for: diagnostic overshadowing (attributing a new physical problem to known psychological factors) [synthesis]. Working if: medical review happens when needed and not otherwise.

B5. Values, small-step goals, activation and graded re-exposure

• Purpose / when: extended basic care and psychotherapy; the guideline prefers active strategies (physical activation, re-exposure where the person spares themselves or avoids, self-help) to passive symptom relief [source: S3].
• Steps:
  1. Clarify broader values and what life the patient wants back [source: S3 "übergeordnete Werte"].
  2. Set realistic, small-step goals jointly [source: S3].
  3. Start with activities the person previously found helpful [source: S3].
  4. For avoided activities, build a graded plan only after the physician has confirmed that the activity is medically safe; agree a rationale and consent; start low and progress by agreement [synthesis; exposure safety].
  5. Review each step: what happened in body, mood and confidence.
  6. Use self-help literature or groups where suitable [source: S3].
• Contraindications and safety [synthesis]: no graded activity without medical clearance where there is unexplained new pain, cardiac or other acute illness, or an eating disorder; adjust or pause if symptoms change in kind.
• Example language (illustrative): "What's one small thing you've stopped doing that you'd like back? Let's make the first step so small it feels almost too easy."
• Watch for: boom-and-bust overactivity; avoidance disguised as "pacing"; symptom flare-ups read as failure. Working if: steps are kept, activity broadens, and flare-ups are tolerated without stopping.

B6. Building motivation for psychotherapy and preparing referrals

• Purpose / when: many patients with bodily complaints do not see themselves as needing psychotherapy; the guideline names therapy motivation as an important first goal and asks for referrals to be prepared carefully [source: S3].
• Steps:
  1. Link therapy to the patient's goals (coping, activity, sleep), not to a claim that the symptom is "psychological".
  2. Offer a trial (a few sessions, then review) [synthesis].
  3. When referring on (e.g. to a specialist in psychosomatic medicine, a psychotherapist or a day clinic), explain the reason, what will happen, and that the physician stays involved [source: S3 gatekeeper; synthesis].
• Example language (illustrative): "This isn't instead of your medical care. It's an extra place to work on how the symptoms are running your life."
• Watch for: the patient experiencing referral as rejection by the physician ("they're passing me on"). Working if: the patient attends and names their own goals.

B7. Reliable contact not tied to symptoms

• Purpose / when: extended care for persistent complaints; the guideline recommends regular appointments independent of the current symptom level, in a calm setting with dependable times [source: S3].
• Steps:
  1. Fix a session rhythm in advance (e.g. same weekday) and keep it whether symptoms are better or worse [synthesis for the specific rhythm].
  2. Do not add sessions only because symptoms flare; instead plan in advance what the patient does in a flare and when to contact the physician [synthesis].
  3. Use attentive listening and follow-up questions to strengthen the relationship [source: S3].
• Example language (illustrative): "We'll meet every other Thursday whether this week is good or bad. You don't need a crisis to earn a session."
• Watch for: contact that only follows escalation (it can reinforce symptom presentation) [synthesis]. Working if: fewer unplanned contacts and calmer sessions.

B8. Communicating evidence and options in dialogue (shared decision-making)

• Purpose / when: whenever options are discussed; the 2004 authors recommend communicating clinical evidence as dialogue rather than protocol, in small, digestible pieces, with "autonomy in relation" [source: Borrell-Carrió et al. 2004].
• Steps:
  1. Ask how much information the patient wants and how they like to decide.
  2. Give one piece at a time; check understanding before the next.
  3. Lay out psychological and social options; for medical options (medication, diet, procedures), help the patient bring their questions to the physician; never advise starting, stopping or changing a medicine [source: Borrell-Carrió et al. 2004 "Mr J" example; synthesis for the scope rule].
  4. Decide together; record what was chosen and why.
• Example language (illustrative): "Would it help if I explained one option at a time, and you stop me whenever it's too much?" / "You'd like to stop the tablets. That's important to raise with Dr K before anything changes. Shall we think about how you'll say it?"
• Watch for: information overload and emotional distancing [source: Borrell-Carrió et al. 2004]; the patient feeling abandoned to decide alone. Working if: decisions are owned, revisited calmly and medical questions reach the right person.

C1. Collaboration with medical teams and the outpatient network

• Purpose / when: every case where a physician is involved; the guideline treats good interdisciplinary cooperation, consultations and agreements between providers as central, keeps the GP or somatic specialist as main contact ("gatekeeper"), asks for an outpatient network to be built before multimodal treatment, and for the whole team to use a deliberate, consistent approach [source: S3]. The specialist societies ask for case and team conferences to be funded [source: DGPM/CPKA/VPKD 2024].
• Steps:
  1. Obtain written consent to exchange information; agree what will and will not be shared [synthesis].
  2. Identify the coordinating physician; send a short letter: your role, formulation summary, therapy goals, agreed warning signs, how to reach you [synthesis].
  3. Agree a consistent message about the explanatory model so the patient hears the same thing from everyone [source: S3 consistent stance; synthesis for method].
  4. Agree who orders tests and who answers medical questions (the physician) [synthesis].
  5. Hold case conferences at key points (stuck progress, escalation, before referral to day-clinic or inpatient care) [source: DGPM/CPKA/VPKD 2024; S3].
  6. Pass on side effects, worsening, warning signs and adherence concerns the patient reports to the prescriber, with consent, or urgently where safety requires [synthesis].
• Example language (illustrative), to a physician: "We're working on activity and sleep and on the worry cycle around the chest pain. We've agreed new or different symptoms come straight to you. Could we align on how we both explain the 'stress turns up the volume' idea?"
• Watch for: splitting (the patient telling each provider a different story); parallel uncoordinated tests; your letters being too long to read. Working if: one plan, one message, fewer duplicated investigations.

C2. Consultation-liaison work in the general hospital

• Purpose / when: psychosomatic consultation is part of hospital psychosomatic work; Uexküll held it necessary even in highly specialised units such as intensive care and bone-marrow transplant wards [source: Kruse; Atarodi et al. 2014]. Detailed C-L procedures are not given in these sources [uncertain].
• Steps [synthesis]:
  1. Clarify the referring team's question and urgency.
  2. Read the notes; speak to the nurse or physician who knows the patient.
  3. See the patient: introduce your role as part of the medical team, assess using A1–A2, including delirium and capacity questions for the medical team to address.
  4. Give a short written answer with concrete recommendations and an explicit risk statement.
  5. Feed back verbally to the team; arrange follow-up or outpatient referral.
• Example language (illustrative): "Your ward team asked me to see you because being in hospital this long is hard on anyone. I'm part of the team looking after you."
• Watch for: a referral that really asks for help with the team's frustration; acute confusion that needs medical, not psychological, assessment. Working if: the team's question is answered and the plan changes in a concrete way.

C3. Psychosomatic basic care (Psychosomatische Grundversorgung): what referring physicians provide

• Purpose / when: know what the GP or specialist with this qualification can do, so work is shared rather than duplicated. The qualification comprises 20 hours of theory, 30 hours of teaching and practice of verbal intervention techniques and 30 hours of Balint group; it is a prerequisite for billing EBM items 35100 and 35110 and is open to physicians of all specialties [source: UKR Regensburg 2026/27]. Topics in one current curriculum: foundations of psychosomatic medicine, diagnostics and biographical history-taking, development of psychosomatic disorders, neurobiology, depression and anxiety, basics of psychopharmacotherapy, communication and verbal intervention, psychotherapy approaches, body-oriented and relaxation methods, crisis intervention and suicide prevention, specialty-specific psychosomatics [source: UKR Regensburg 2026/27]. About 55,000 physicians held it according to Kruse [source: Kruse].
• Steps (for the psychotherapist):
  1. Ask whether the referring physician offers basic psychosomatic care; if so, agree that they continue regular short contacts while you provide psychotherapy [synthesis].
  2. Share the explanatory model so both use the same language [synthesis].
  3. Use the physician as gatekeeper for medical decisions (C1).
• Example language (illustrative), to a patient: "Dr K will keep seeing you regularly for the medical side, and here we'll work on how you cope. We'll keep each other informed."
• Watch for: assuming the physician has time for long talks; Grundversorgung is not psychotherapy [synthesis]. Working if: roles are clear to the patient.

C4. Referral to, and work around, day-clinic and inpatient psychosomatic treatment

• Purpose / when: severe courses where outpatient care is impossible or insufficient [source: S3]. German inpatient psychosomatics offers multimodal intensive programmes ("psychosomatische Komplexbehandlung") that keep a link to everyday life, integrate somatic and psychosomatic diagnosis, and combine several psychotherapy sessions per week with art, music, movement and nutrition therapies [source: DGPM/CPKA/VPKD 2024; Kruse].
• What one programme involves (Heidelberg, Station and Day Clinic Mitscherlich, 2020 brochure) [source: Heidelberg brochure]: 19 inpatient and 3 day-clinic places; usual stay about 8 weeks, first two weeks a trial and orientation phase; somatic examination and blood tests by the ward physician on admission; patients assigned to a group track focused on emotion and conflict or on stabilisation and resources; individual therapy with physicians or psychologists; psychodynamic-interactional group, theme-centred interactional (TZI) group, stabilisation group; concentrative movement therapy (KBT); art-based "Gestaltungstherapie"; primary nursing ("Bezugspflege") with nurse-led resource group, stabilisation training, progressive muscle relaxation and mindfulness; social therapy (work, housing, money, contacts) and a social-skills group; couples/family sessions; weekly therapeutic ward round with therapist, physician and nurse; weekend home trials ("Belastungserprobung") from the second weekend; questionnaires at admission, discharge and six months later; crisis stays require that the patient can make agreements and distance themselves from suicidal acts; no alcohol or drugs, and repeated rule breaches lead to a review of the therapeutic alliance. Programmes differ between hospitals [synthesis].
• Steps (for the outpatient psychotherapist):
  1. Discuss with the coordinating physician and patient whether criteria are met (severity, impairment, failed outpatient care) [source: S3; synthesis].
  2. Explain what a multimodal stay is like (group-heavy, body and creative therapies, ward rules, home trials) so the patient arrives prepared [source: Heidelberg brochure; synthesis].
  3. With consent, send the clinic your formulation and what has and has not helped [synthesis].
  4. Agree before discharge who provides outpatient follow-up and when; the societies favour a step-down concept with earlier outpatient follow-up and institute outpatient clinics (PSI) to bridge the gap [source: DGPM/CPKA/VPKD 2024].
  5. After discharge, help transfer what worked into everyday life; review home-trial experiences [synthesis].
• Example language (illustrative): "A day clinic or ward isn't a sign you've failed. It's a few weeks of more intensive work, and I'll be here afterwards."
• Watch for: the drop after discharge; the patient experiencing the trial phase as a test they might fail. Working if: gains hold over the first months after discharge.

C5. Psychological care alongside chronic physical illness

• Purpose / when: patients with chronic somatic illness and psychological comorbidity, a core group of German psychosomatics [source: DGPM/CPKA/VPKD 2024]; Engel's own 1980 example was a heart attack patient [source: Engel 1980 abstract].
• Steps [synthesis]:
  1. Assess adjustment, fear of progression, mood and the illness's effect on roles and relationships (A1–A3).
  2. Work on coping, meaning, communication with the medical team and with family.
  3. Explore ambivalence about medical treatment and adherence openly, without advising any change; route every medication question to the prescriber (B8).
  4. Ask about side effects or new symptoms and pass them on (C1).
  5. Watch for blaming attributions ("my stress gave me the heart attack") and soften them into multi-factor accounts [source: Borrell-Carrió et al. 2004 on blaming attributions].
• Never present psychotherapy as treating the disease itself [synthesis].
• Example language (illustrative): "We can't treat the diabetes here; that's your diabetes team. What we can work on is how worn down you feel by managing it every day."
• Watch for: guilt from "mind over body" narratives picked up elsewhere; depression hidden behind physical explanations. Working if: the patient feels less alone with the illness and engages with medical care.

C6. Crisis and safety planning

• Purpose / when: suicidality, acute crises; crisis intervention and suicide prevention are part of the basic-care curriculum [source: UKR Regensburg 2026/27]; inpatient crisis stays assume the patient can make safety agreements [source: Heidelberg brochure].
• Steps [synthesis, standard practice]: structured risk assessment; collaborative written safety plan (warning signs, coping, people and places, professional contacts, emergency numbers); lethal-means counselling (safe storage, removal of means, including stockpiled medicines handled with the prescriber or pharmacist); inform the physician; arrange emergency psychiatric assessment where risk is acute.
• Example language (illustrative): "Sometimes when pain goes on this long, people think about not wanting to be here. Has that crossed your mind?"
• Watch for: hopelessness about the illness; access to medicines. Working if: the plan is written, shared and used.

C7. Clinician self-awareness, calibration and Balint work

• Purpose / when: ongoing; the 2004 authors place self-awareness, self-calibration and emotion education at the centre of biopsychosocial practice, and the S3 guideline notes that clinician behaviour markedly shapes the course [source: Borrell-Carrió et al. 2004; S3]. Balint groups (case discussion and reflection) are a required part of basic psychosomatic care training [source: UKR Regensburg 2026/27].
• Steps:
  1. After difficult sessions, note your feelings (frustration, helplessness, rescue wishes) and what triggered them [source: Borrell-Carrió et al. 2004].
  2. Check for bias: sex, race, premature closure [source: Borrell-Carrió et al. 2004].
  3. Trace intuitive doubts to concrete observations [source: Borrell-Carrió et al. 2004].
  4. Bring cases with strong reactions to a Balint group, supervision or intervision [source: UKR; synthesis for supervision].
• Example language (illustrative), self-talk: "I'm irritated that she brought new symptoms again. What is this irritation telling me about her situation, and about mine?"
• Watch for: labelling patients "difficult" or "heartsink" [synthesis]. Working if: you approach the next session with curiosity rather than dread.

C8. Cultural humility and context

• Purpose / when: all cases; a cited study found that a physician committed to the model still produced misunderstanding and distrust in interviews with Native American patients [source: Benning 2015, citing Bartz 1999], and the model has been criticised for treating culture as homogeneous within groups [source: Benning 2015, citing Hatala 2012].
• Steps [synthesis]: ask about the patient's cultural and religious understanding of illness and healing; ask about previous experiences with health services, including discrimination; adapt explanations to the patient's frame; use professional interpreters.
• Example language (illustrative): "In your family or community, how would people usually explain symptoms like these?"
• Watch for: assuming you know a culture's view from group membership. Working if: the patient's own frame appears in the shared model.

5. Handling problems

Most responses below are the guide's own synthesis; source-based points are tagged.

"You're saying it's all in my head"

• Response: acknowledge the hurt; restate credibility; explain "both-and" and "turning up the volume" (B1); do not argue. Return to the body and to function [source: S3 for credibility and both-and; synthesis for wording].
• Illustrative: "I'm sorry it sounded like that. I'm not saying the pain is imagined. I'm saying your body and your life are both involved, and both deserve attention."

Repeated demands for more tests or a second opinion

• Response: do not oppose or endorse tests; explore what the test is meant to settle (B3); help the patient discuss it with the coordinating physician; support the physician's restraint with tests that mainly serve reassurance [source: S3]. A second opinion is the patient's right; ask that results come back to one coordinator [synthesis].
• Watch for: your own anxiety leading you to suggest tests.

Patient feels blamed or guilty for their illness

• Response: move from "cause" to "conditions, triggers, amplifiers" [source: S3]; show multiple factors, including those outside the patient's control; name that attributions can blame and worsen symptoms [source: Borrell-Carrió et al. 2004].

Stuck: symptoms unchanged, therapy circling

• Response: return to function and values rather than symptom intensity; revise the 4P formulation; check perpetuating factors in all three columns (e.g. social benefits conflicts, family roles, sleep, untreated depression); case conference with the physician; consider the next care step (multimodal, day clinic, inpatient, rehabilitation) [source: S3 stepped care; PsychDB for revising the formulation; synthesis].

Resistance to any psychological framing

• Response: work on goals the patient endorses (sleep, activity, coping with doctors); treat motivation as the first goal [source: S3]; offer a time-limited trial; keep the physician involved so referral is not felt as rejection.

Overwhelm or symptom flare during activation or exposure

• Response: pause, return to an earlier step, check with the physician about any new symptom; normalise flare-ups as expected within agreed limits; never push through new or changed symptoms without medical review [synthesis; exposure safety].

Non-adherence to homework or activity plans

• Response: make steps smaller; check whether the rationale was understood and shared; look for fear of harm; consider whether the plan was yours rather than theirs [synthesis].

Non-adherence or ambivalence about medical treatment

• Response: explore reasons (side effects, fears, beliefs, cost) without judgement; do not advise any change; help the patient raise it with the prescriber and, with consent, inform the prescriber [synthesis; scope rule].

Splitting and conflicting messages between providers

• Response: call a short case conference; agree one explanatory model and one coordinator; document the agreement [source: S3 consistent stance and gatekeeper; DGPM/CPKA/VPKD 2024 case conferences; synthesis].

Ruptures (patient angry, missed sessions after a hard conversation)

• Response: name the rupture; take your share; return to the patient's illness theory (A2); renegotiate goals. Maintain the fixed rhythm (B7) so contact does not depend on symptoms or conflict [synthesis].

Clinician frustration, helplessness or rescue wishes

• Response: self-calibration and Balint or supervision (C7) [source: Borrell-Carrió et al. 2004; UKR 2026/27].

New or changing physical symptoms during therapy

• Response: always route to the physician; never assume they are part of the known psychological pattern (diagnostic overshadowing) [synthesis]; the guideline's red flags are to be reassessed throughout [source: S3].

Inpatient-specific problems

• Trial phase doubts: the first two weeks are explicitly a joint assessment of fit [source: Heidelberg brochure]; help the patient see it as a two-way check.
• Rule breaches (alcohol, relationships between patients): the programme may review the alliance or discharge [source: Heidelberg brochure]; prepare patients for the rules before admission [synthesis].
• Relapse after discharge: arrange outpatient follow-up before discharge (step-down) [source: DGPM/CPKA/VPKD 2024; synthesis].

Critiques and their practical implications

• Too loose to guide practice. Ghaemi (2009, 2011) argued that the model allows an undisciplined "eclectic freedom" bordering on anarchy [source: Benning 2015]. Implication: use a structured formulation (A4) and a stated treatment rationale, not a list of everything [synthesis].
• Rebuttal. Kendler (2010) replied that Ghaemi offered no alternative to a model still useful in teaching and practice [source: Benning 2015].
• Philosophical coherence. Borrell-Carrió et al. (2004) note that nothing in Engel's dualist framing itself guides clinicians to empathy or genuineness, and that Engel was not fully faithful to complexity theory; they reject the label "new paradigm" and value the model for applying existing knowledge parsimoniously [source: Borrell-Carrió et al. 2004; Benning 2015].
• Not a valid model / wrong theory base. McLaren (1998) argued general systems theory is the wrong sort of theory for a model of mind; Benning rejects this [source: Benning 2015].
• Endorsement is not practice. Endorsing the model does not guarantee empathy or trustworthiness, and its claimed effect on clinician understanding is rarely tested [source: Benning 2015]. Implication: train and monitor the relational skills explicitly (Section 3, C7) [synthesis].
• Medically unexplained symptoms. Butler et al. (2004) argued the model fails to explain such symptoms, which need an interpretivist perspective [source: Benning 2015]. Implication: weigh the patient's meanings (A2) as heavily as the factor list [synthesis].
• Culture and large systems. The model is criticised for treating culture positivistically and for neglecting community, culture and society levels [source: Benning 2015]. Implication: C8.
• Biomedical dominance persists. Pilgrim (2002) and empirical surveys cited by Benning report that published psychiatry and health psychology remain largely biomedical [source: Benning 2015].
• Uexküll on specialisation. Uexküll had wanted psychosomatics integrated into all of medicine and did not intend it to become a separate specialty [source: Atarodi et al. 2014]. Implication: even within a specialist service, keep the integration task alive with every medical colleague [synthesis].

Sources

Web pages and documents

• The need for a new medical model: a challenge for biomedicine (PubMed record; Engel, Science 1977;196(4286):129–36)
• The clinical application of the biopsychosocial model (Am J Psychiatry 137(5):535; abstract page)
• Borrell-Carrió F, Suchman AL, Epstein RM. The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry. Ann Fam Med 2004;2(6):576–582
• Benning T. Limitations of the biopsychosocial model in psychiatry. Adv Med Educ Pract 2015;6:347–352
• Uexküll, Thure von — Neue Deutsche Biographie (Deutsche Biographie), 2016 (German)
• Atarodi S, Rafieian Sh, Salavati M. Thure von Uexküll's Contribution to German Psychosomatic and Psychosocial Medicine: An Interview. Int J Body Mind Culture 2014;1(2):97–101
• Roenneberg C, Sattel H, Schaefert R, Henningsen P, Hausteiner-Wiehle C. Klinische Leitlinie "Funktionelle Körperbeschwerden" (S3, AWMF 051-001, short version; Dtsch Arztebl 2019;116:553–560) (German)
• Psychosomatische Grundversorgung 2026/2027, Abteilung für Psychosomatische Medizin, Universitätsklinikum Regensburg (German)
• Positionspapier der psychosomatischen Verbände DGPM, CPKA und VPKD (2024) (German)
• Kruse J. Ärztliche Psychotherapie – ihr Wert für die Patientenversorgung aus der psychosomatischen Perspektive (slides, Bundesärztekammer, 2015/2017) (German)
• Psychotherapeutische Station und Tagesklinik Mitscherlich, Patientenbroschüre, Universitätsklinikum Heidelberg, Dec 2020 (German)
• PsychDB. Biopsychosocial Case Formulation (teaching page, last edited July 2026)

Books and papers cited

• Engel GL (1977). The need for a new medical model: a challenge for biomedicine. Science 196:129–136.
• Engel GL (1980). The clinical application of the biopsychosocial model. Am J Psychiatry 137:535 [uncertain: page range not verified].
• Uexküll T von (ed.) (1979). Lehrbuch der psychosomatischen Medizin; from the 3rd edition (1986) Psychosomatische Medizin (as reported by NDB).
• Uexküll T von, Wesiack W (1988). Theorie der Humanmedizin (as reported by NDB).
• Barker P (1995) and Weerasekera P (1993), sources of the 4P grid as credited by PsychDB [uncertain: titles not verified].
• Ghaemi SN (2009, 2011); Kendler KS (2010); McLaren N (1998); Pilgrim D (2002); Butler CC et al. (2004); Hatala AR (2012); Bartz R (1999): critiques as summarised in Benning (2015) [uncertain: titles not verified].

Translations from German sources are the guide's own brief paraphrases.