The Problem of Work Stress and the Need to Re-imagine the Bio-Psycho-Social Model

  • David WainwrightEmail author
  • Elaine Wainwright


The popular discourse of work stress adopts a realist ontology derived from bio-medicine. Stress is viewed as a set of adverse physiological responses to objective characteristics of work. More sophisticated approaches admit that ‘appraisal’ mediates the relationship between stressor and stress response, but appraisal is viewed largely as a function of individual traits and characteristics. The ‘epidemic’ of work stress is thus explained as an inevitable response to a putative intensification of labour which has pushed an increasing number of workers beyond the ‘natural’ limit of human endurance.

Social constructionists have challenged the popular discourse of work stress, arguing that what appears to be a universal and natural category is in essence an historically and culturally specific construct—it is the phenomenal form through which antagonisms at work are experienced and explained in contemporary Western societies. This radical critique sparked the ‘stress-wars’ around the turn of the century, but despite subsequent skirmishes little has changed either in the public imagination or scientific discourse. There are many reasons for the impasse, but the embodied nature of stress is in our opinion the most significant. For the stressed worker experiencing the fight or flight response, and for the physiologist clutching cortisol swabs and fibrinogen counts, work stress cannot be magicked away by deconstruction. The critique of work stress has had little traction, not because it lacks empirical support but because it contradicts the lived experience of the stressed body. While many can accept that social factors such as poverty can impact on the body, the belief that narratives can be written on the body is harder to accept. This incredulity stems from the weaknesses of the ways in which the dominant bio-psycho-social model is currently conceptualised. Our argument is that the critique of work stress is unlikely to succeed without a more critical engagement with the bio-psycho-social model.

When the bio-psycho-social model emerged in the 1970s, it was heralded as a necessary correction to the dehumanising biological reductionism claimed to typify medical practice at the time. By recognising the social origins of illness and the role of psychological factors in mediating illness behaviour, the new approach would open the doors to forms of practice that were more humane and more effective. Much empirical work has been done on the intersections of the model, yet it remains under-theorised; three separate perspectives, overlapping peripherally, rather than a truly unified general theory. Substantial obstacles lie in the way of such a synthesis, not least the mind/body problem and the structure/agency debate. The bio-psycho-social model offers no route out of these culs-de-sac. Our aim is to critique the bio-psycho-social model, but also to transcend it, by formulating a new theoretical framework that draws upon post-dualist ontology and social constructionism. The latter is a much more hubristic project and a work in progress. Here, we present our current conceptualisation. We have named this the triple-helix theory of the self, because it replaces static notions of the biological, psychological and social with a more dynamic conception of the corporeal, discursive and environmental, spiralling around each other across the life course, giving rise to a uniquely human self.


  1. Borrell-Carrió, F., Suchman, A. L., & Epstein, R. M. (2004). The biopsychosocial model 25 years later: Principles, practice, and scientific inquiry. The Annals of Family Medicine, 2(6), 576–582.Google Scholar
  2. Buck, R., Wynne-Jones, G., Varnava, A., Main, C. J., & Phillips, C. J. (2009). Working with musculoskeletal pain. Reviews in Pain, 3(1), 6–10.Google Scholar
  3. Bury, M. (1982). Chronic illness as biological disruption. Sociology of Health & Illness, 4(2), 167–182.Google Scholar
  4. Checkland, K., Harrison, S., McDonald, R., Grant, S., Campbell, S., & Guthrie, B. (2008). Biomedicine, holism and general medical practice: Responses to the 2004 General Practitioner contract. Sociology of Health & Illness, 30(5), 788–803.Google Scholar
  5. Chew-Graham, C., & May, C. (1999). Chronic low back pain in general practice: The challenge of the consultation. Family Practice, 16(1), 46–49.Google Scholar
  6. Eccleston, C., Williams, A. C., & Rogers, W. S. (1997). Patients’ and professionals’ understandings of the causes of chronic pain: Blame, responsibility and identity protection. Social Science and Medicine, 45(5), 699–709.Google Scholar
  7. Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129–136.Google Scholar
  8. Foucault, M. (1973). The birth of the clinic: An archaeology of medical perception. London: Routledge.Google Scholar
  9. Foucault, M. (1988). Technologies of the self: A seminar with Michel Foucault. (L. H. Martin, H. Gutman, & P. H. Hutton, Eds.). London: Tavistock.Google Scholar
  10. Frank, A. W. (1991). For a sociology of the body: An analytical review. In M. Featherstone, M. Hepworth, & B. S. Turner (Eds.), The body: Social process and cultural theory. London: Sage.Google Scholar
  11. Freeman, J. (2005). Towards a definition of holism. British Journal of General Practice, 55(511), 154–155.Google Scholar
  12. Galvin, R. (2002). Disturbing notions of chronic illness and individual responsibility: Towards a genealogy of morals. Health, 6(2), 107–137.Google Scholar
  13. Gatchel, R. J., McGeary, D. D., McGeary, C. A., & Lippe, B. (2014). Interdisciplinary chronic pain management: Past, present, and future. American Psychologist, 69(2), 119.Google Scholar
  14. Ghaemi, S. N. (2009). The rise and fall of the biopsychosocial model. British Journal of Psychiatry, 195, 3–4.Google Scholar
  15. Giddens, A. (1991). Modernity and self-identity: Self and society in the late modern age. Cambridge: Polity Press.Google Scholar
  16. Grönlund, A. (2007). More control, less conflict? Job demand–control, gender and work–family conflict. Gender, Work & Organization, 14(5), 476–497.Google Scholar
  17. Hagen, R., Hjemdal, O., Solem, S., Kennair, L. E. O., Nordahl, H. M., Fisher, P., et al. (2017). Metacognitive therapy for depression in adults: A waiting list randomized controlled trial with six months follow-up. Frontiers in Psychology, 8, 31.Google Scholar
  18. Halligan, P., Bass, C., & Oakley, D. (Eds.). (2003). Malingering and illness deception. Oxford: Oxford University Press.Google Scholar
  19. Huber, M., van Vliet, M., Giezenberg, M., Winkens, B., Heerkens, Y., Dagnelie, P. C., et al. (2016). Towards a ‘patient-centred’ operationalisation of the new dynamic concept of health: A mixed methods study. BMJ Open, 6(1), e010091.Google Scholar
  20. Kivimäki, M., Nyberg, S. T., Batty, G. D., Fransson, E. I., Heikkilä, K., Alfredsson, L., et al. (2012). Job strain as a risk factor for coronary heart disease: A collaborative meta-analysis of individual participant data. The Lancet, 380(9852), 1491–1497.Google Scholar
  21. Mabry, P. L., Olster, D. H., Morgan, G. D., & Abrams, D. B. (2008). Interdisciplinarity and systems science to improve population health: A view from the NIH Office of Behavioral and Social Sciences Research. American Journal of Preventive Medicine, 35(2), S211–S224.Google Scholar
  22. Main, C., Foster, N., & Buchbinder, R. (2010). How important are back pain beliefs and expectations for the satisfactory recovery from back pain? Best Practice and Research Clinical Rheumatology, 24(2), 205–217.Google Scholar
  23. May, C. (2005a). Chronic illness and intractability: Professional–patient interactions in primary care. Chronic Illness, 1, 15–20.Google Scholar
  24. May, C. (2005b). Epidemiological, social and political dimensions of chronic disease. Chronic Illness, 1, 28–29.Google Scholar
  25. McLaren, N. (1998). A critical review of the biopsychosocial model. Australian and New Zealand Journal of Psychiatry, 21, 619–624.Google Scholar
  26. Moraes, L. J., Miranda, M. B., Loures, L. F., Mainieri, A. G., & Mármora, C. H. C. (2018). A systematic review of psychoneuroimmunology-based interventions. Psychology, Health & Medicine, 23(6), 635–652.Google Scholar
  27. Pillastrini, P., Gardenghi, I., Bonetti, F., Capra, F., Guccione, A., Mugnai, R., et al. (2012). An updated overview of clinical guidelines for chronic low back pain management in primary care. Joint Bone Spine, 79(2), 176–185.Google Scholar
  28. Pulvirenti, M., McMillan, J., & Lawn, S. (2014). Empowerment, patient centred care and self-management. Health Expectations, 17(3), 303–310.Google Scholar
  29. Rathert, C., Wyrwich, M. D., & Boren, S. A. (2013). Patient-centered care and outcomes: A systematic review of the literature. Medical Care Research and Review, 70(4), 351–379.Google Scholar
  30. Ray, O. (2004). How the mind hurts and heals the body. American Psychologist, 59(1), 29.Google Scholar
  31. Reid, J., Ewan, C., & Lowry, E. (1991). Pilgrimage of pain: The illness experiences of women with repetitive strain injury and the search for credibility. Social Science and Medicine, 32, 601–612.Google Scholar
  32. Rosewilliam, S., Roskell, C. A., & Pandyan, A. D. (2011). A systematic review and synthesis of the quantitative and qualitative evidence behind patient-centred goal setting in stroke rehabilitation. Clinical Rehabilitation, 25(6), 501–514.Google Scholar
  33. Slavich, G. M. (2016). Life stress and health: A review of conceptual issues and recent findings. Teaching of Psychology, 43(4), 346–355.Google Scholar
  34. Strong, P. M. (1979). The ceremonial order of the clinic: Parents, doctors and medical bureaucracies. London: Routledge and Kegan Paul.Google Scholar
  35. Townsend, P. (1993). The international analysis of poverty. London: Routledge.Google Scholar
  36. Townsend, P. (2010). The meaning of poverty. The British Journal of Sociology, 61(s1), 85–102.Google Scholar
  37. Waddell, G. (1998). The back pain revolution. Edinburgh: Churchill Livingstone.Google Scholar
  38. Waddell, G. (2006). Preventing incapacity in people with musculoskeletal disorders. British Medical Bulletin, 77–78(1), 55–69.Google Scholar
  39. Wainwright, D., & Calnan, M. (2002). Work stress: The making of a modern epidemic. Buckingham: Oxford University Press.Google Scholar
  40. Wainwright, D., Calnan, M., O’Neil, C., Winterbottom, A., & Watkins, C. (2006). When pain in the arm is ‘all in the head’: The management of medically unexplained suffering in primary care. Health, Risk and Society, 8(1), 43–58.Google Scholar
  41. Wainwright, D., Wainwright, E., Black, R., & Kenyon, S. (2012). Reconstructing the self and social identity: New interventions for returning long-term incapacity benefit recipients to work. In S. Vickerstaff, C. Phillipson, & R. Wilkie (Eds.), Work, health and wellbeing: The challenges of managing health at work. Bristol: Policy Press.Google Scholar
  42. Wainwright, E., Wainwright, D., Keogh, E., & Eccleston, C. (2015). The social negotiation of fitness for work: Tensions in doctor–patient relationships over medical certification of chronic pain. Health, 19(1), 17–33.Google Scholar
  43. Watson, P. J., Bowey, J., Purcell-Jones, G., & Gales, T. (2008). General practitioner sickness absence certification for low back pain is not directly associated with beliefs about back pain. European Journal of Pain, 12(3), 314–320.Google Scholar
  44. Wertli, M. M., Burgstaller, J. M., Weiser, S., Steurer, J., Kofmehl, R., & Held, U. (2014). Influence of catastrophizing on treatment outcome in patients with nonspecific low back pain: A systematic review. Spine, 39(3), 263–273.Google Scholar
  45. Williams, S., & Bendelow, G. (1998). The lived body: Sociological themes, embodied issues. London: Routledge.Google Scholar

Copyright information

© The Author(s) 2019

Authors and Affiliations

  1. 1.Department for HealthUniversity of BathBathUK
  2. 2.Department of PsychologyBath Spa UniversityBathUK

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